CDA Journal - August 2020: Oral Health Literacy

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A S S O C I AT I O N

Oral Health Literacy

Healthy People Initiative Oral Health Equity Health Literacy Roundtable

Hope for Better Understanding Lindsey A. Robinson, DDS

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40 years and counting V IS IO N + FOC US + S T R E NG TH What does it mean to be built by dentists?

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Aug. 2020

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d e pa r t m e n t s

363 The Editor/Where Have All the Assistants Gone?

365 Letter to the Editor 367 Impressions 405 RM Matters/Returning To Work: A Compassionate Approach to Staff Well-Being

409 Regulatory Compliance/COVID-19 and Respiratory Protection

411 Ethics/Is It Ethical To Ask for Reviews?

412 Tech Trends

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f e at u r e s

371 Oral Health Literacy: Hope for Better Understanding An introduction to the issue.

Lindsey A. Robinson, DDS

373 The 2030 Healthy People Initiative and Framework: Health Literacy’s Impact on Oral Health Promotion and Disease Prevention Objectives for the Nation This paper discusses oral health in the context of this framework and implications for supporting progress toward the new objectives.

Dushanka V. Kleinman, DDS, MScD; Alice M. Horowitz, PhD; Rima E. Rudd, PhD; Donald L. Rubin, PhD; Kathryn A. Atchison, DDS, MPH; and Cynthia Baur, PhD

383 American Dental Association: Advancing Health Literacy Within and by the Dental Profession This article summarizes the ADA’s efforts to improve the oral health literacy of the public and current and future dental professionals.

Sharon R. Clough, RDH, MS Ed

389 Health Literacy: A Path to Oral Health Equity This paper discusses how everyone should have equal access to appropriate health information with which they can make informed decisions.

Homa Amini, DDS, MS, MPH, and James R. Boynton DDS, MS

397 Improving Oral Health Literacy in California: A Perspective This commentary discusses how oral health literacy is critical to advance oral health for all.

Jayanth Kumar, DDS, MPH

400 National Academies of Sciences, Engineering and Medicine: Dentistry’s Valuable Investment in the Health Literacy Roundtable This proceeding discusses the work of the Roundtable on Health Literacy.

Lindsey A. Robinson, DDS

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Journa C A L I F O R N I A

D E N TA L

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

CDA Officers Richard J. Nagy, DDS President president@cda.org

A S S O C I AT I O N

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Kristine Allington Chief Marketing Officer Alicia Malaby Communications Director

Editorial

Judee Tippett-Whyte, DDS President-Elect presidentelect@cda.org

Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org

Ariane R. Terlet, DDS Vice President vicepresident@cda.org

Ruchi K. Sahota, DDS, CDE Associate Editor

John L. Blake, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org R. Del Brunner, DDS Immediate Past President pastpresident@cda.org

Volume 48 Number 8 August 2020

Brian K. Shue, DDS, CDE Associate Editor Gayle Mathe, RDH Senior Editor Lindsey A. Robinson, DDS Guest Editor Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Senior Communications Specialist

Blake Ellington Tech Trends Editor

Manuscript Submissions

Journal of the California Dental Association Editorial Board

Jack F. Conley, DDS Editor Emeritus

www.editorialmanager. com/jcaldentassoc

Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

Robert E. Horseman, DDS Humorist Emeritus

Letters to the Editor

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Production Randi Taylor Senior Visual Designer

Upcoming Topics September/Ethics October/Sugar November/Dental Student Research

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Subscriptions Annual subscriptions are available to association members at a rate of $36.

Advertising Sue Gardner Advertising Sales Sue.Gardner@cda.org 916.554.4952

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

Permission and Reprints

Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif.

Andrea LaMattina, CDE Publications Manager Andrea.LaMattina@cda.org 916.554.5950

Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco

The Journal of the California Dental Association (ISSN 1043–2256) 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.

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

Copyright 2020 by the California Dental Association. All rights reserved.

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

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

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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.

Editor

C D A J O U R N A L , V O L 4 8 , Nº 8

Where Have All the Assistants Gone?

Kerry K. Carney, DDS, CDE

F

irst, a blanket apology to Pete Seeger for commandeering and altering the title of the best antiwar ballad ever written. Seeger sang a story of generations lost in the flower of their youth to the graveyards of war. This variation on the ballad’s title reflects the storyteller’s slow unfolding of a new world, a sad recognition that times have changed. The world we live and practice in is not the same as it was in 1955 when Seeger’s song was published.

Three years ago, I started hearing colleagues complain about how hard it was to find dental assisting staff. It was hard not to feel a little smug about having a good, reliable complement of staff members. This was, of course, hubris; the only constant is change.

In my mind, staffing issues were simply a problem for those who did not treat their staff well or did not pay them a reasonable wage or were somehow unreasonable in their employment demands. When we lost a longtime dental assistant, we were frog-marched into the new reality. We tried to make our practice stand out to lure applicants.

Our ads got us very few responses. The few applicants we interviewed used us to leverage other employment offers.

We found ourselves joining the chorus: Where have all the assistants gone?

Urban hipsterfication was making it difficult to impossible for entry-level employees like dental assistants to find affordable housing in the cities. But the affordable housing crisis was not the sole cause of the dwindling numbers of job applicants. The applicant pool for dental assisting positions is just not the same as it was in 1955.

When Dr. C. Edmund Kells hired Malvina Cueria in 1885, she became

The flexibility and the easy-in, easy-out employment that characterizes the digital economy may have contributed to the reduction in candidates that previously supplied the dental field. recognized as the first staff member hired as a dental assistant. In those days, dental assistants were also known as “ladies in attendance.” One of their primary duties was to act as chaperones and facilitate the treatment of female patients without the need for the presence of a male relative.

Now dental assistants fulfill a much greater role and are an integral part of our professional team. When a longtime dedicated member of the dental team leaves for any reason – change of family demands, change of living circumstances, change of career goals, etc., it can be very traumatic to the practice, the patients and the remaining staff. It can feel like a death in the family. But life moves on and the practice has to seek a replacement for the missing staff person. In the past, there were many experienced applicants and many inexperienced but motivated and reliable applicants eager to join the dental team. Today, not so much.

In 2017, the CDA House of Delegates voted to establish a taskforce to investigate the problem articulated by a number of dental society components: Where have all the assistants gone? Some of their findings follow.

The decline in applicants for entrylevel positions is not restricted to the field of dentistry. There are many economic influences on the entry- and mid-level job markets that have resulted in a reduced applicant pool. Technology companies

may be perceived as offering a better or higher paying career than dental assisting. Employment environments have changed. The numbers of individuals working from home or working remotely have been on a dramatic and continuous rise since the 1990s. The flexibility and the easy-in, easy-out employment that characterizes the digital economy may have contributed to the reduction in candidates that previously supplied the dental field. There are jobs now that simply did not exist in the past. Whoever heard of a barista before Starbucks?

Dental office hours may also be a problem. Many offices see the majority of their appointment requests for times after school. Working these hours can make child rearing difficult for the employee.

The costs of dental assisting training programs may be deterring new candidates from entering the field. Training programs range from $1,000 to $16,000 in tuition and from nine months to two years in duration. Though financial aid may be available, the prospect of taking on educational debt may be a significant barrier to prospective candidates.

Several schools reported in a survey that they had seen a decrease in enrollment over the last few years.

They also reported an increase in students who were not prepared to be successful in the educational process or in the dental assisting field, AUGUST 2 0 2 0 363

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EDITOR C D A J O U R N A L , V O L 4 8 , Nº 8

citing tardiness and absenteeism as concerns. They also reported that highperforming students were recruited directly into hygiene programs.

The taskforce pointed out that the dwindling number of assistant applicants meant human resource companies that perform the service of locating and hiring employees added dental assisting to their portfolio. These services are bundled with other HR services and the sticker shock for the hiring dentist can be significant.

The final recommendations of the taskforce focused on: workforce development, defining a career pipeline,

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facilitating licensure portability, streamlining resources at CDA Practice Support, improving knowledge of the dentist’s role in the employer-employee relationship, communicating the importance of nonsalary support for assistants and developing the dentist’s crucial conversations skills.

Dentists have to change and adapt to the new employment environment.

But let me tell you what finally worked for us. We contacted all the local assisting programs and offered to provide extern training opportunities for their students.

Our very first extern impressed us all. She has joined our team, and we hope we will

not have to do this again for another 17 years. But in the meantime, we will be promoting the career of dental assisting to everyone who will listen. It is a great chance to have a little personal impact on the supply of dental assistants for dentists in the future. Explaining the emotional and financial benefits our hands-on field of medicine can offer may broaden the horizon of employment opportunities for those interested in a new career.

And if we do not let others know how rewarding the oral health care field can be, when will they ever learn? When will they ever learn? (Sorry again, Pete.) n

Letter

C D A J O U R N A L , V O L 4 8 , Nº 8

Digital Discussion Hello Kerry, I write to inquire if the online CDA Journal is temporary and if it will go back to print?

After 35 years of looking forward to reading the Journal at night, the last thing I want to look at is a computer screen.

Thank you and very best, Hugo hugo v. schmidt, dds

Greenbrae, Calif.

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ADEA Compendium Objective Structured Clinical Examinations Licensure by Portfolio

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Dear Kerry, Thank you for your reply. However you became the CDA Journal editor, clearly your insightful, articulate writing must have some connection.

The irritation of the Journal going digital went away as soon as I hit the email “send” button to you.

It completely makes sense and the timing right. The cost savings must be substantial. Running the CDA has got to be expensive. The value of being a CDA member has never been more evident as right now.

CDA’s emails, webinars and work with the state and TDSC regarding the pandemic have been tremendously impressive. It’s certainly helped my simple business stay on track.

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Dear Hugo, I empathize. I am a “print girl.” I pay an exorbitant amount of money every month to have a print version of a national newspaper delivered to my house every day. I relish the time I spend reading it every morning. I love the feel, the smell, the organization and the ease of reading. I enjoy the fact that if I can’t get to it in the morning, I can read it in the bath without worrying about dropping it in the water (a mistake that could be very costly if I were reading it on an electronic device.)

However, from my first day as editor (12 years ago), there have been discussions about transitioning the Journal to a digital format. There are cost savings realized through eliminating the printing and mailing of the Journal to our 27,000 members that cannot be dismissed. Considering the rapidly changing information environment we are experiencing during this pandemic, it seemed like a good time to lead our readers to a timelier information-gathering experience.

One of our goals is to make our authors’ articles more accessible and sharable so that their research can have a greater impact. We also want to remain the resource for oral health care information for our state and national

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Greater Impact, Reader Benefits

policymakers as well as provide public health trends for our members so they understand the greater environment in which they practice. We continue to strive to act as a translational medium to help practitioners incorporate new information and effective therapies and techniques into their practices.

Other reader benefits are accessible only through a digital format, but it is clear that, “After 35 years of looking forward to reading the Journal at night, the last thing [you] want to look at is a computer screen.”

I thank you for your longtime loyalty, and I truly hope you can continue to enjoy the Journal. As far as I know, there are no plans to return to a print version.

With your permission, I would like to “print” your letter to the editor in an upcoming issue of the Journal. I feel sure you are not the only reader with this question.

Sincerely, Kerry K. Carney, DDS, CDE Editor-in-Chief California Dental Association

(As an aside, the Journal had an essayist for a number of years, David Chambers, who typically approached a subject in dentistry that is a real challenge: ethics. A simple one-page, three to four paragraph essay, which always ended with “the nub” and which required further thought, was a favorite along with letters to the editor and your column.)

On second thought, next month will be 40 years including dental school! I love dentistry and I’ve been incredibly lucky to have had the mentors I’ve had. The wonderful team I get to work with, nice patients and a specialty that is constantly challenging all make it fun. That’s a lot of time gone by when it feels like I just got out of training.

As far as publishing my comments as a letter to the editor, be my guest.

My friends will get a good laugh …

Thank you for your efforts on behalf of the CDA! Very best, Hugo

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Business loan options Patient screening Practice interruptions Local ordinances & regulations Leaves of absence Infection control Dental billing &time telehealth Paid & unpaid off Patient communication Employeevs. communication Mandates recommendations Termination & unemployment escheduling appointments License Sick leaverenewal policies & C.E. HIPAA considerations nformed consent forms

NEW & COMPLEX QUESTIONS? Today, the countless sources and rapid pace of news make it more challenging than ever to navigate the business side of dentistry. That’s why CDA’s Practice Support analysts have developed new tools to guide members through the COVID-19 crisis and toward practice recovery. Access 24/7 online resources and tap into specialized expertise on practice management, compliance, employment and dental benefits.

TRUSTED ANSWERS. cda.org/practicesupport

TOGETHER WE ARE LIMITLESS

Impressions

C D A J O U R N A L , V O L 4 8 , Nº 8

Dental Care and COVID-19

Dental professionals should take this opportunity to assess the role of dental care in a public health emergency, look into the future and determine what we can improve to better serve our patients and protect our staff should a similar event happen again.”

— JOCELYNE FEINE, DDS, MS

Rapid testing for infectious diseases such as COVID-19 in dental offices using saliva samples may be valuable in the early identification of infected patients and in disease progress assessment, according to a commentary by researchers at the University of Rochester, Eastman Institute for Oral Health in New York on the impact of COVID-19 on dental care and oral health. The commentary was published in JDR Clinical & Translational Research.

The authors reviewed current evidence related to the impact of SARS-CoV-2/COVID-19 on dental care and oral health with the aim to help dental professionals better understand the risks of disease transmission in dental settings, strengthen protection against nosocomial infections and identify areas of COVID-19 related oral health research.

Their research revealed that the COVID-19 pandemic has exposed significant gaps in the collective response of global health care systems to a public health emergency and that dentistry, as an integral part of the health care system, should be prepared to play a more active role in the fight against emerging life-threatening diseases.

The commentary also suggests that in addition to conducting rapid testing in the dental office, dental education, research, clinical practices and public health should consider the following aspects during and after the COVID-19 pandemic: ■ Evidence supports that oral mucosa is an initial site of entry for SARS-CoV-2 and that oral symptoms, including loss of taste and smell and dry mouth, might be early symptoms of COVID-19, although the mechanism and prognosis of oral symptoms of COVID-19 are not clear.

■ Improving public health emergency preparedness throughout the dental health care system, such as including fit testing of N95 respirators and the proper donning and doffing of masks and isolation gowns in the dental training curriculum and dental practice routine.

■ Increasing research efforts in aerosol control in dental offices, including improving engineering control in dental office design to reduce risk of transmission for infectious respiratory diseases.

■ Initiating and participating in scientific research projects to discover the impact of COVID-19 and other infectious diseases on oral health.

“Though dentistry is a relatively small part in the COVID-19 response, dental professionals should take this opportunity to assess the role of dental care in a public health emergency, look into the future and determine what we can improve to better serve our patients and protect our staff should a similar event happen again,” said JDR Clinical & Translational Research Editor-in-Chief Jocelyne Feine, DDS, MS. Read more of this commentary in JDR Clinical & Translational Research (2020); doi.org/10.1177%2F2380084420924385. n AUGUST 2 0 2 0 367

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Fluoride in Water Not Linked to Osteosarcoma (Credit: McDevitt Lab/NYU College of Dentistry)

College of Dentistry App Gauges COVID-19 Severity A new mobile app developed by researchers at the NYU College of Dentistry can help clinicians determine which patients with COVID-19 are likely to have severe cases. The app uses artificial intelligence (AI) to assess risk factors and key biomarkers from blood tests, producing a COVID-19 “severity score,” according to the study published in the journal Lab on a Chip.

Using data from 160 hospitalized COVID-19 patients in Wuhan, China, the researchers identified four biomarkers measured in blood tests that were significantly elevated in patients who died versus those who recovered. These biomarkers can signal complications that are relevant to COVID-19, including acute inflammation, lower respiratory tract infection and poor cardiovascular health.

The researchers then built a model using the biomarkers as well as age and sex, two established risk factors. They trained the model using a machine learning algorithm, a type of AI, to define the patterns of COVID-19 disease and predict its severity.

The model was validated using data from 12 hospitalized COVID-19 patients from Shenzhen, China, which confirmed that the model’s severity scores were significantly higher for the patients who died versus those who were discharged.

The researchers further validated the model using data from more than 1,000 New York City COVID-19 patients.

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Community water fluoridation is not associated with increased risk of osteosarcoma, according to a Harvard School of Dental Medicine study published in the Journal of Dental Research.

The study assessed whether living in a fluoridated community was a risk factor for osteosarcoma by performing a secondary data analysis using data collected from two separate but linked studies. Patients for both Phase 1 and Phase 2 were selected from U.S. hospitals using a hospital-based matched case-control study design. For both phases, cases were patients diagnosed with osteosarcoma and controls were patients diagnosed with other bone tumors or non-neoplastic conditions.

In Phase 1, cases (N = 209) and controls (N = 440) were patients of record in the participating orthopedic departments from 1989–1993. In Phase 2, cases (N = 108) and controls (N = 296) were incident patients who were identified and treated by orthopedic physicians from 1994–2000.

This analysis included all patients who met eligibility criteria on whom researchers had complete data on covariates, exposures and outcome.

Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association of community water fluoridation with osteosarcoma.

The adjusted OR for osteosarcoma and ever-having lived in a fluoridated area for nonbottled water drinkers was 0.51 (0.31–0.84), p = 0.008. The same comparison adjusted OR for bottled water drinkers was 1.86 (0.54– 6.41), p = 0.326.

“These results indicate that residence in a fluoridated community is not related to an increase in risk for osteosarcoma after adjusting for race, ethnicity, income, distance from the hospital, urban/rural living status and drinking bottled water,” said Chester Douglass, DMD, PhD, of the Harvard School of Dental Medicine, Department of Oral Health Policy and Epidemiology.

Learn more about this study in the Journal of Dental Research (2019); doi.org/ 10.1177%2F0022034520919385.

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app that can be used at point-of-care to quickly calculate a patient’s severity score.

Because this technology is currently used for research and informational purposes only, the app can be used only with existing laboratory tests and requires oversight by an authorized clinician.

However, over the next few months,

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the NYU laboratory, in partnership with SensoDx, plans to develop and scale the ability to test a drop of blood for COVID-19 severity biomarkers and produce a severity score on the spot.

Learn more about the app’s development in Lab on a Chip (2020); doi.org/10.1039/D0LC00373E.

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Bacteria Assemble Army of Protection for Teeth Taking a 3D approach to studying bacteria, researchers at the University of Pennsylvania School of Dental Medicine and the Georgia Institute of Technology found that Streptococcus mutans is encased in a protective multilayered community of other bacteria and polymers forming a unique spatial organization associated with the location of the onset of caries. The study was published in the journal Proceedings of the National Academy of Sciences.

The research team imaged the bacteria that cause tooth decay in three dimensions in their natural environment: dental plaque formed on toddlers’ teeth that were affected by cavities. They used a combination of super-resolution confocal and scanning electron microscopy with computational analysis to dissect the arrangement of S. mutans and other microbes of the intact biofilm on the teeth. These techniques

Harnessing Pickle Power for Dental Health Can a probiotic derived from Chinese pickles prevent caries? That seems to be the case, according to a study by researchers at Ben-Gurion University of the Negev and Chengdu University in China and published in Frontiers in Microbiology. The study found a strain of Lactobacilli (L. plantarum K41) in Sichuan pickles reduced Streptococcus mutans by 98.4%.

Pickles are an integral part of the diet in the southwest of China. When fruits and vegetables are fermented, healthy bacteria break down the natural sugars.

These bacteria, also known as probiotics, not only preserve foods but offer numerous benefits, including immune system regulation, stabilization of the intestinal microbiota, reducing cholesterol levels and now inhibiting tooth decay.

The objective of the study was to screen Lactobacillus strains found in traditional Sichuan pickles and to evaluate their antagonistic properties against S. mutans in vitro and in vivo. Researchers evaluated 14 different types of Sichuan pickles from southwest China, extracting 54 different strains of Lactobacilli. One strain, L. plantarum K41, showed the highest inhibitory effect on S. mutans growth as well as on the formation of exopolysaccharides (EPS) and biofilm in vitro.

Scanning electron microscopy (SEM) and confocal laser scanning microscope (CLSM) revealed the reduction of both EPS and of the network-like structure in S. mutans biofilm when these bacteria were co-cultured with strain L. plantarum K41.

Furthermore, when rats were treated with strain L. plantarum K41, there was a significant reduction in the incidence and severity of dental caries.

Read more of this study in Frontiers in Microbiology (2020); doi.org/10.3389/ fmicb.2020.00774.

Streptococcus mutans, labeled in green, shields itself under layers of other bacteria, enabling it to stick stubbornly to the enamel. (Credit: Dongyeop Kim)

allowed the team to examine the biofilm layer by layer, gaining a 3D picture of the specific architectures.

The researchers discovered that S. mutans in dental plaque most often appeared in a particular fashion: arranged in a mound against the tooth’s surface.

While S. mutans formed the inner core of the rotund architecture, other commensal bacteria, such as S. oralis, formed additional outer layers precisely arranged in a crownlike structure. Supporting and separating these layers was an extracellular scaffold made of sugars produced by S. mutans, effectively encasing and protecting the disease-causing bacteria.

To learn more about how structure impacted the function of the biofilm, the research team attempted to recreate the natural plaque formations on a toothlike surface in the lab using S. mutans, S. oralis and a sugar solution.

They successfully grew rotund-shaped architecture, then measured levels of acid and demineralization associated with them. The team discovered that the rotund areas perfectly matched with the demineralized and high-acid levels on the enamel surface, which mirrors the white spots clinicians see when they find dental caries. Hence, the domelike structure could explain how caries get their start.

Learn more about this study in Proceedings of the National Academy of Sciences (2020); doi.org/ 10.1073/pnas.1919099117.

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introduction C D A J O U R N A L , V O L 4 8 , Nº 8

Oral Health Literacy: Hope for Better Understanding Lindsey A. Robinson, DDS

GUEST EDITOR Lindsey A. Robinson, DDS, is a board-certified pediatric dentist and has maintained a dental practice in Grass Valley, Calif., since 1996. She received her certificate in pediatric dentistry from the University of Florida and dental degree from the University of Southern California. Dr. Robinson is a past president of the California Society of Pediatric Dentistry and the California Dental Association (CDA) and served as chair of the CDA Foundation. She was a member of the American Dental Association Council on Access, Prevention and Interprofessional Relations (now called CAAP) for six years, and during her tenure served as chair for two years. Dr. Robinson 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.

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his issue of the Journal of the California Dental Association is dedicated to oral health literacy and is the second issue to explore the subject. Following the first issue published in 2012, the contents demonstrate a shift in thinking on how health literacy should be “defined” while maintaining the core belief that health literacy is crucial to optimizing population and individual health. Moving away from focus on individual abilities, there is now acknowledgment that health literacy is multidimensional and influenced by system complexities, social and cultural factors, environmental conditions and communication context. This evolution is reflected in commentary from the Secretary of the Health and Human Service’s (HHS) Advisory Committee on National Health Promotion and Disease Prevention objectives for Healthy People 2030 that, “Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.”

As we all know too well, this country is grappling with an unprecedented public health crisis that has upended all segments of society and changed the way people go about their daily lives. At this writing, the number of COVID-19 cases are rising exponentially in 36 states. Reliable, clear and timely communication is especially

crucial in this time of uncertainty where people have been inundated with volumes of information about the virus.

Sifting through and identifying what is accurate, nascent and applicable has become overwhelming for many. As our knowledge of the SARS-CoV-2 virus expands, it is incumbent upon health care providers to create a safe space to deliver clinical care, help people assess their individual health risks and understand how to prevent the spread of disease.

The issue begins with a thorough discourse on the federal initiative called Healthy People (HP) written by members of the HHS Secretary’s Advisory Committee. It begins at inception with the landmark 1979 “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention” with the goal of developing a set of evidencebased, measurable objectives to improve the health of the nation. The article goes on to describe the soon to be released 2030 iteration, which incorporates oral health into the framework and, for the first time, health literacy to promote progress toward the HP 2030 goals.

The next offering is by retired ADA Manager of Preventive Health Services, Sharee R. Clough, RDH, MS Ed. “American Dental Association: Advancing Health Literacy Within and by the Dental Profession” provides an update on the “National Plan to Improve AUGUST 2 0 2 0 371

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Health Literacy in Dentistry” developed by the ADA-supported National Advisory Committee on Health Literacy in Dentistry established nearly a decade ago.

Over the years, the association has made great progress in addressing plan goals as reflected in numerous policies adopted and support of cross-cutting activities that guide the profession’s efforts to improve the oral health literacy of the nation.

In “Health Literacy: A Path to Oral Health Equity,” Homa Amini, DDS, MS, MPH, and James R. Boynton, DDS, MS, describe how oral health professionals can work at both the systems and individual levels to obtain health equity by utilizing health literacy principles.

They remind the reader that social determinants have a critical influence on health outcomes and are drivers of health inequities between groups of people.

California State Dental Director Jayanth Kumar, DDS, MPH, offers his perspective on improving oral health literacy in California through several initiatives from the State Department of Oral Health. One

initative is a toolkit aimed to assist dental providers in communicating with patients and caregivers on oral health promotion and the reduction of dental diseases, which was developed in collaboration with Linda Neuhauser, DrPH, MPH, of Berkeley’s Health Research for Action.

Finally, this author provides background on the Health Literacy Roundtable, under the umbrella of the National Academies of Science, Engineering and Medicine, and the important contributions the field of oral health has made to it over the years.

They include development of the Dental Collaborative that led to a commissioned paper and workshop focused on exploring the integration of oral and general health through the use of health literacy practices. Both the commissioned paper and workshop proceedings are examples of the influence the field of oral health brings to ongoing national conversations on improving the health of the nation.

My sincere appreciation goes to the authors who are all passionate champions

of oral health literacy and willingly gave their time and expertise to bring this Journal issue to fruition. They exhibited great patience as the publication date shifted to accommodate a variety of needs and issues related to the pandemic. Special thanks go to Dushanka V. Kleinman, DDS, MS, and Alice M. Horowitz, PhD, for spearheading the manuscript that comprehensively captures the 2030 HP Initiative and to other Advisory Committee members who contributed to it.

“The single biggest problem in communication is the illusion that it has taken place.” This quote by George Bernard Shaw speaks to how health literacy is foundational to ensure mutual understanding and improves the ability of people to act on information that makes it easier to access, understand and use health information and health services.

The dental profession and greater oral health community must continue to find and invest in opportunities to articulate that oral health is critical to optimizing the health and well-being of all people. n

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healthy people C D A J O U R N A L , V O L 4 8 , Nº 8

The 2030 Healthy People Initiative and Framework: Health Literacy’s Impact on Oral Health Promotion and Disease Prevention Objectives for the Nation Dushanka V. Kleinman, DDS, MScD; Alice M. Horowitz, PhD; Rima E. Rudd, PhD; Donald L. Rubin, PhD; Kathryn A. Atchison, DDS, MPH; and Cynthia Baur, PhD

a b s t r a c t Oral health is an integral part of the Healthy People initiative, a 40-

year national health promotion and disease prevention effort that sets and monitors objectives with data-driven targets for each decade. The framework for the next decade, Healthy People 2030, includes new components and a focus on health literacy for the first time. This paper discusses oral health in the context of this framework and implications for supporting progress toward the new objectives.

AUTHORS Dushanka V. Kleinman, DDS, MS, MScD, is the principal associate dean and a professor in the department of epidemiology and biostatistics at the University of Maryland School of Public Health in College Park.

Conflict of Interest Disclosure: None reported.

Alice M. Horowitz, PhD, is a research associate professor in the department of behavioral and community health at the University of Maryland School of Public Health in College Park.

Conflict of Interest Disclosure: None reported.

Rima E. Rudd, PhD, is a senior lecturer in the health literacy, education and policy department of social and behavioral sciences at the Harvard T.H. Chan School of Public Health in Boston.

Conflict of Interest Disclosure: None reported.

Donald L. Rubin, PhD, is an emeritus professor in the departments of speech communication and language and literacy education and in the program of linguistics at the University of Georgia in Athens.

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.

Cynthia Baur, PhD, i s an endowed professor and the director of the Horowitz Center for Health Literacy at the University of Maryland School of Public Health in College Park.

Conflict of Interest Disclosure: None reported.

T

he topic of oral health has been an integral part of the Healthy People initiative, a 40-year national health promotion and disease prevention effort launched by Surgeon General Julius Richmond’s landmark 1979 report “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.”1 This report challenged the nation to do more collectively to improve the health of the population and highlighted the importance of setting science-based objectives with targets each decade to guide coordinated efforts and drive action. The development of Healthy People 2030 is now underway AUGUST 2 0 2 0 373

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HHS Secretary’s Advisory Committee

HHS ODPHP

and includes a framework and new objectives with targets to chart the course for the coming decade. The framework explains the context and rationale for Healthy People 2030 and provides principles that underlie decisions about the initiative. In January 2019, the draft national objectives, including a number of oral health objectives, were circulated for public comment. The U.S. Department of Health and Human Services (HHS) is anticipated to launch Healthy People 2030, the fifth iteration of the initiative, in late summer of 2020.

The first section of the paper outlines the history and oral health components of the initiative. The second section describes new components of the Healthy People 2030 framework relevant to overall health and well-being, one of which is the inclusion of health literacy for the first time. It goes on to examine how oral health and health literacy fit within the framework. The discussion focuses on implications for oral health promotion and disease prevention and how the framework can inform oral health literacy and support preparation for and progress toward the Healthy People 2030 objectives.

Section One: History of the Healthy People Initiative

The Healthy People initiative is federally led and stakeholder driven (FIGURE 1 ). HHS coordinates the initiative with the support of a federal interagency workgroup that includes representatives from each of the HHS agencies and other federal agencies. In addition, subject-matter experts from across HHS support the development, assessment and management of topic-specific objectives.

Coordinators in each state further extend the reach of this initiative nationally and into local communities. From the beginning of the initiative, the critical role of multisector collaborations and 374 AUGUST

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Federal interagency workgroup (28 federal agencies) State and local governments (50 state coordinators)

National-level stakeholders including members of the Healthy People Consortium (2,200+ volunteers)

Community-based organizations, community health clinics, social service organizations, etc.

Individuals, families and neighborhoods across America Office of Disease Prevention and Health Promotion, Department of Health and Human Services.

Presented to the Secretary’s Advisory Committee on Dec. 1, 2016, during its inaugural meeting.

FIGURE 1. Health People 2020: federally led, stakeholder-driven process.

concerted efforts at the local level to promote health was acknowledged. The 1979 surgeon general’s report recognized that progress will require “the commitment of people extending far beyond what we traditionally consider the health sector,” and that such action is possible only through “a partnership that involves the serious commitment of individual citizens, the communities in which they live, the employers for whom they work, voluntary agencies and health professionals.”1 At the time of the initial launch in 1979, the Healthy People initiative was innovative and unique in its design. It created a roadmap composed of carefully selected topics with quantifiable targets and provided a highly visible, data-driven report card of the nation’s health improvements and challenges. The approach, with its projection and monitoring of targets and reporting of progress at the middle and end of each decade, stimulated interest across the nation and in other countries.

Now, 40 years later, this data- and evidence-based health promotion and disease prevention initiative continues to inform national, local, state and international initiatives (TABLE ).

Since 1980, specific national objectives have been established with targets to be achieved by the close of the decade.

Throughout the decade for each iteration of the initiative, formal assessments of progress are conducted at various intervals, including topic-specific progress reviews, a mid-decade review and an end-of-decade final review. With each decade, the overarching goals have expanded in scope and emphasis and the number of Healthy People objectives and topic areas has increased. Two overarching goals guided the 1990 objectives: decrease mortality for infants through adults and increase independence among older adults.2 By 2020, the scope of the overarching goals expanded the reach of the initiative: attain high-quality, longer lives free of preventable disease; achieve health equity and eliminate health disparities; create social and physical environments that promote good health; and promote quality of life, healthy development and healthy behaviors across life stages.3 In addition to the overarching goals, the number of objectives and related topics grew from 226 objectives with 15 topics for 1990 to 1,300 objectives with 42 topics for 2020.

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TABLE

The Evolution of Healthy People Target year

1990

Overarching goals

n

n

Decrease mortality: infants–adults Increase independence among older adults

2000 n

Increase span of healthy life

n

Reduce health disparities

n

Achieve access to prevention services for all

2010 n

n

2020

Increase quality and years of healthy life

n

Eliminate health disparities n

n

n

Attain high-quality, longer lives free of preventable disease Achieve health equity; eliminate disparities Create social and physical environments that promote good health Promote quality of life, healthy development, health behaviors across life stages

Number of topic areas

15

22

28

39*

Number of objectives/measures

226/NA

312/NA

467/1,000

> 580/1,200

* With objectives Office of Disease Prevention and Health Promotion, Department of Health and Human Services. Presented to the Secretary’s Advisory Committee on Dec. 1, 2016, during its inaugural meeting.

This evolution reflects an increase in scientific knowledge and the interest of collaborating organizations and advocacy groups. It also speaks to the growing understanding of the multiple factors contributing to health and well-being.

Oral Health Components of Healthy People

Targets for improvements in oral and dental health status, disease preventive measures and surveillance activities have been included in each decade since the inception of the Healthy People initiative.

This has offered the opportunity for greater national visibility to oral health as an essential condition of overall health and well-being. Over the decades, the oral health objectives have grown in number and scope, reflecting the evolving structure of Healthy People as well as of the emerging professional and public health interests and issues. The objectives first appeared under the topic of “fluoridation and dental health,” but thereafter continued with each decade under the topic of “oral health.” With each decade, the number of oral health objectives has increased. The inclusion

of oral health objectives addressing oral and dental health issues indicate increased diversification with additional disease targets, preventive services and infrastructure systems and reflect extension into dental-medical integration.

For 1990, 12 objectives addressed improving health status (dental caries and gingivitis in children and periodontal diseases in adults) as well as reducing risk factors (decreasing highly cariogenic foods and snacks in schools and wearing mouthguards during sports).2 The initial oral health objectives called for increasing professional and public awareness by increasing schoolchildren and adults’ knowledge and awareness of dental disease risk factors and of the importance of fluoride and other measures to control disease. This includes increasing awareness of personal oral hygiene and the importance of professional care among adults as well as increasing personal oral hygiene and other preventive measures for schoolchildren. The objectives also included system-level changes such as improving services (access to community water supplies with optimum fluoride

and provision of school water supplies with optimum fluoride when community water supplies are not possible.)

Furthermore, the objectives addressed improving surveillance and evaluation systems, specifically, a system for periodic determination of oral health status, treatment needs and use of services as well as a system to determine coverage of all major preventive measures and actions to reduce consumption of highly cariogenic foods. The structure of these objectives paralleled that of other health objectives and followed the charge that these objectives were primarily designed for healthy individuals to reduce risks to future illness, not just for the early detection of existing diseases.

Oral health objectives continued to be expanded in number and scope for Healthy People 2000, 2010 and 2020.3–5 In Healthy People 2020, the oral health topic area includes 33 objectives and represents a more detailed profile of targets that expanded the focus on early detection, systems of care and surveillance.3 Objectives move beyond the profession’s and public’s increased awareness and knowledge of preventive measures and AUGUST 2 0 2 0 375

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Total objectives: 33

instead include measures of receipt of preventive services and measures of the inclusion of oral health components of school-based health centers, federally qualified health centers and local health departments. The addition of objectives to increase adults receiving oral and pharyngeal cancer screening, introduced in 2010, and for the testing and referral for glycemic control by dentists and dental hygienists reflect the continued emphasis on and the importance of integration of medical-dental practice. Expansions in measuring oral health status include untreated dental caries, tooth loss and oral-cancer detection. Expansions in surveillance and monitoring include the increase of state-based surveillance systems for oral and craniofacial conditions and for systems to record and refer infants and children with cleft lip or cleft palate to craniofacial anomaly rehabilitation teams. In addition, an objective was added to increase health agencies with a dental public health program directed by a dental professional with public health training. Healthy People 2020 also provides linkages among topic areas.

For the topic of oral health, linkages with cancer, diabetes, tobacco use, access to care and others are highlighted.

The Healthy People initiative has provided the oral health community with a common roadmap to guide efforts at local, state, regional, tribal and federal levels with resources highlighting evidence-based interventions. It also has highlighted areas and gaps where additional investments are needed. For example, early in this national initiative, the need for access to timely, high-quality data to inform state and local prevention and health promotion efforts was identified. A concerted effort by the Association of State and Territorial Dental Directors with support from the Centers for Disease Control and Prevention’s Division of Oral Health established 376 AUGUST

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Measurable 100% (n = 33)

Measurable objectives: 33

Getting worse 30% (n = 1) Little or no detectable change 15.2% (n = 5)

Baseline only 24.2% (n = 8)

Target met or exceeded 48.5% (n = 16)

Improving 9.1% (n = 3) FIGURE 2 . Midcourse status of oral health objectives.

the National Oral Health Surveillance System.6 This included the creation of oral health indicators and the inclusion of oral health questions in surveys, such as the Behavioral Risk Factor Surveillance System. Continued investments in surveillance efforts are critical to program development, assessment and redirection.

The Healthy People 2020 Midcourse Review oral health findings provide another example of how this initiative can be used to assess and inform our programmatic efforts and decision-making (FIGURE 2 ).7 The report reveals positive progress: 16 of 33 oral health objectives had met or exceeded their 2020 targets and another three of 33 oral health objectives were improving. The Healthy People 2020 Midcourse Review further revealed that five oral health objectives had little or no detectable change — children with dental caries experience in their primary and permanent teeth (aged 6–9 years); adolescents with dental caries experience in their permanent teeth (aged 13–15 years); adults with moderate or serious periodontitis (aged 45–74 years); oral and pharyngeal cancers detected in the earliest stage; and federally qualified health centers with an oral health care program. One oral health objective was getting worse — children, adolescents and adults who visited the dentist in the past year (age-adjusted, percent, aged 2-plus

years: from 44.5% to 42.1%) — and eight oral health objectives had baseline data only and progress could not be measured.

The latter objectives highlighted the lack of data regarding: older adults (aged 75+ years) with untreated root surface caries; adults who received information on reducing tobacco use from a dentist; adults who received an oral cancer screening from a dentist; and adults who were tested or referred for glycemic control by a dentist and local health departments with oral health prevention or care programs. The Healthy People midcourse and final decade reports, like this one for Healthy People 2020, provide the health professions and policymakers with critical data to inform actions to be taken. These data serve as the initial stage to inform additional assessments into facilitators and barriers to achieve the objective targets and highlight gaps in needed surveillance and infrastructure.

With the anticipated release of the Healthy People 2030 final objectives in late summer 2020, oral health professionals can benefit from the Healthy People 2020 assessments and begin the process of alignment with the new Healthy People 2030 framework. The 2030 framework provides insight to the advance preparation and strategic approaches needed to support progress toward the newly formulated oral health and related objectives.

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Healthy People 2030 Framework: Vision, Mission, Foundational Principles and Overarching Principles Section Two: Healthy People 2030 Framework

The framework for Healthy People 2030 provides a guide to the objectives and the implementation of initiatives.8 The sidebar highlights select components of the framework: the vision, mission, foundational principles (new to the Healthy People initiative) and overarching goals. The health literacy component is a new and integral part of the foundational principles and of the overarching goals (attaining health literacy, eliminating health disparities, achieving health equity). In addition, several other concepts differentiate the framework for 2030 from that of Healthy People 2020. These include the cross-cutting emphasis on “health and well-being” throughout the framework as well as the principle that promoting the health and well-being of the nation is a “shared responsibility” among all levels and sectors. Included is attention to economic environments, in addition to the social and physical environments, to strengthen the potential to achieve health and wellbeing. Furthermore, the engagement of the public, key constituents and leadership to take action and design effective policies is highlighted. Research findings from health literacy offer insight for these additional concepts and can serve as a foundational component of Healthy People 2030 to “improve the health and well-being of all,” including oral health.

Health Literacy as a Foundational Concept

While the topic of health literacy is relatively new to the Healthy People initiative (introduced 20 years after the inception of Healthy People), its inclusion and evolution reflect the growth of the scientific research foundation and increased understanding of its role as a determinant of health. The topic was

Vision: A society in which all people can achieve their full potential for health and wellbeing ac ross the lifespan.

Mission: To promote, strengthen and evaluate the nation’s effort to improve the health and well-being of all people.

Foundational principles: Health and well-being of all people and communities are essential to a thriving, equitable society.

Promoting health and well-being and preventing disease are linked efforts that encompass physical, mental and social health dimensions.

Investing to achieve the full potential for health and well-being for all provides valuable benefits to society.

Achieving health and well-being requires eliminating health disparities, achieving health equity and attaining health literacy.

Healthy physical, social and economic environments strengthen the potential to achieve health and well-being.

Promoting and achieving the nation’s health and well-being is a shared responsibility that is distributed across national, state, tribal and community levels, including the public, private and nonprofit sectors.

Working to attain the full potential for health and well-being of the population is a component of decision-making and policy formulation across all sectors.

Overarching goals: Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death.

Eliminate health disparities, achieve health equity and attain health literacy to improve the health and well-being of all.

Create social, physical and economic environments that promote attaining full potential for health and well-being for all.

Promote healthy development, healthy behaviors and well-being across all life stages.

Engage leadership, key constituents and the public across multiple sectors to take action and design policies that improve the health and well-being of all.

Healthy People 2030 Framework, healthypeople.gov/2020/About-Healthy-People/Development-HealthyPeople-2030/Framework.

introduced at the turn of the century in the 2010 Healthy People objectives and was included in the 2020 objectives. The 2010 document defined health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”5 The measure focused on health literacy skills of the English-

speaking population and noted that only 12% of this population was proficient. In addition, the definition of “oral health literacy” was included in the oral health chapter. However, no objectives specific for oral health literacy were included.

For 2020, the health literacy objectives continued to address the health literacy of the population and added a measure of increasing “the proportion of persons AUGUST 2 0 2 0 377

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who report that their health care providers have satisfactory communication skills.”

This reflected a growing awareness of the evolution of the health literacy concept — one that is attentive to the literacy skills of the public along with the health literacy and communication skills of health professionals, the quality of health information and various attributes of the health care system.

Issue Brief on Health Literacy

To clarify concepts included in the Healthy People 2030 framework, the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Secretary’s Advisory Committee) prepared several issue briefs to inform the development and implementation of Healthy People 2030.9 The issue brief on “health literacy” offers a review of this topic in the Healthy People initiative, provides a general overview of health literacy as a determinant of health and discusses the need for an expanded concept of health literacy. It offers a discussion of limited health literacy and its association with poor health outcomes, health disparities, reductions in health care quality and increased health care costs.

The brief provides evidence of how major national and international organizations have recognized the role of health literacy in reducing health disparities, improving quality of care and improving population health (World Health Organization, National Academies of Science, Engineering and Medicine, the Joint Commission and National Committee for Quality Assurance). The emerging perspective is that enhancing the population’s health literacy requires a systems approach and argues for a conceptual model of health literacy “as a process,” one that engages several contributing factors. The Secretary’s Advisory Committee concluded: “Health 378 AUGUST

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literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.” “Society” includes health care providers, mass and social media, health care facilities and organizations and more.

In addition, “people” includes individuals and communities, including health care providers. Furthermore, it notes: “Healthy People 2030 can catalyze new, systemwide health care and public health-oriented policies, standards and measures that strategically include attention to health

“Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.” literacy.” The brief concludes that “to attain health literacy, interventions targeting the complex factors contributing to or mediating health literacy are needed at all levels: individual, community and society.” The emphasis is placed “on aligning the information and services that society provides with the capacities of people” and that “this alignment is pivotal to eliminating health disparities and achieving health equity.”

Oral Health in the Context of the Healthy People 2030 Framework

The multidimensional aspects of oral health — the physical, psychological, emotional and social domains — are complex and require clearly communicated information to inform coordinated actions among sectors and settings.10 The July

2019 Lancet review of the global oral health challenge echoes key messages from “Oral Health in America: A Report of the Surgeon General” that were highlighted 20 years earlier.11,12 These messages reinforce that oral health is more than healthy teeth and highlight the integral role oral health plays for our overall health, well-being and quality of life. They also note that the disproportionate burden of oral diseases falls on society’s vulnerable populations. This occurs in the context of the existence of evidence-based interventions to prevent major oral health diseases and the sharing of risk factors, such as tobacco and alcohol, common to other diseases where interventions can have a magnified impact on overall health.

Several essential aspects of the Healthy People 2030 framework magnify aspects of oral health that may not be as visible to the broader health and health policy community and add several key concepts not previously articulated. In addition, the framework provides an opportunity to view oral health through a health literacy lens.

First, we note that Healthy People 2030 added emphasis on health and well-being, which provides the opportunity to consider how the two states — health and well-being — relate to one another.

Healthy People 2010 proposed that they should be seen as mutually reinforcing each other. The Secretary’s Advisory Committee’s Healthy People 2030 brief on health and well-being asserts that health and well-being can be defined as “how people think, feel and function — at a personal and social level — and how they evaluate their lives as a whole.”9 For Healthy People 2030, well-being was added to the health-related, qualityof-life initiative and was viewed from a multidimensional perspective incorporating self-rated physical and mental health, the sense of overall well-being and a sense of participation in society.

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Clearly, oral health and well-being can well fit into this construct. We have long considered oral health as the absence of disease. This view was reflected in the objectives and measures that had been used for the earlier Healthy People initiatives.

However, we have also long understood the critical role of oral and craniofacial structures and health to our daily functioning — affecting our ability to speak, chew and smile — and its contribution to how we feel about our overall oral health and general health status.13 Yet, conversations in the literature, at professional meetings and with policymakers tend to focus on health care services and treatment of diseases. An expanded oral health concept captures important quality-of-life measures as well as the importance of services and treatment.

Next, we note that the Healthy People 2030 framework has included economic environments in addition to social and physical environments to strengthen the potential to achieve health and well-being.

The economic impact of oral health and well-being is given limited visibility, yet it is well-known that poor oral health undermines employment and productivity.

Measures, such as days lost from work, oral health status factors that compromise employability and days lost from school, reflect that this aspect of our health warrants attention.14,15 One frequently cited economic model estimated that improving health literacy could reduce an annual burden of $106 billion to $238 billion to the U.S. economy.16 No doubt that estimate would be even higher were the impact of low oral health literacy adequately incorporated.

The framework explicitly connects health disparities, health equity and health literacy. Indeed, while many social determinants of health are very resistant to reform, health literacy appears much more tractable and therefore a promising route to reduce disparities.17 The vicious bidirectional spiral that links poor oral

health and social and economic fragility for many individuals in our society may be largely invisible to the general public. For example, individuals who are incarcerated in the criminal justice system are at high risk of poor dental health with little access to preventive or acute care. At the same time, the pain and distraction of acute dental disease may contribute to behavior patterns that put individuals at greater risk of incarceration.18 Employing health literacy best practices with these fragile populations might prove an especially sound investment.19

The economic impact of oral health and well-being is given limited visibility, yet it is well-known that poor oral health undermines employment and productivity.

In addition, we note that promotion and maintenance of oral health demands an understanding of culture and society and a shared responsibility among several sectors: between individuals and professionals, among various professionals and among the lay public, professionals and health systems. Evidence-based interventions that promote oral health exist and can be applied by individuals, communities and professionals. These interventions range from basic self-care with a fluoride-containing dentifrice to programs such as community water fluoridation and school-based dental sealant programs. Public benefit will accrue through continual communication and education of entities at all levels (local, state, national and tribal) and sectors (public, private, not for profit).

One of the key challenges lies in the continual need to communicate oral health knowledge, new findings and benefits of practice. Communication with people, whether they are patients, providers, community residents or policymakers, must be developed and delivered in a manner that meets the needs of each group. This includes attention to people’s language and scientific understanding, as well as to the use of information for decision-making and action. This is closely aligned with the framework’s emphasis on the importance of engaging the public, key constituents and leadership to take action and design effective policies.

Finally, this issue of communication brings us to the importance of drawing from findings and insights in health literacy.

The Secretary’s Advisory Committee’s health literacy brief provides a broader concept of health literacy than had been articulated earlier in Healthy People 2010.

This health literacy lens now offers a focus on the literacy skills and ability of members of the lay public as well as on the health literacy and communication skills of health professionals; the reading skills of the public as well as on the quality of health texts; the communication skills of professionals and the norms of health and health care practices; and the navigation skills of the public and the facilitating factors and hindrances found in health and health care offices, institutions and systems. Health literacy research indicates that changes in texts, in communication practices and in the characteristics of health institutions and systems have the potential to improve health literacy and thereby influence health outcomes. FIGURE 3, adapted from the Institute of Medicine’s sentinel report “Health Literacy: A Prescription to End Confusion,”20 provides a visual that highlights key factors influencing oral health literacy and ultimately contributes to oral health and well-being outcomes.

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2 Health systems

Health Literacy, Oral Health Literacy and Integration of Health Care

The year 2000 was a banner year for oral health literacy in that it was first mentioned in Healthy People 2010 and subsequently in “Oral Health in America: A Report of the Surgeon General.”11 Oral health literacy first appeared in the Healthy People 2010 oral health chapter released in 2000, which included this definition of oral health literacy: “The degree to which individuals have the capacity to obtain, process and understand basic oral health information and services needed to make appropriate health decisions.”5 Further, in 2003, “A National Call to Action to Promote Oral Health” was published, which further established the need for increasing oral health literacy to help ensure improved oral health for all, especially for vulnerable groups.21 While great strides have been made in increasing oral health literacy, much more is needed to achieve the Healthy People 2030 objectives. Fostering improved oral health literacy at all levels requires significant education, training, research and resources.

Improved oral health literacy of patients, the public, health care providers and policymakers requires their understanding that science-based preventive regimens exist for most oral diseases. Yet these regimens are not routinely being applied by health care providers and a large proportion of the public and policymakers are unaware of them. Moreover, patients cannot request them personally and policymakers are unaware of the potential for improved health of the public. Most individuals, including health care providers, social workers and policymakers, are unaware of the importance and impact of oral health on general health and vice versa. To help educate the public and policymakers, all health providers and staff members who interact with patients 380 AUGUST

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3

1 Culture and society

Oral health literacy

Oral health outcomes and costs

Education system

(Adapted from Figure 2-2 in Kindig DA, Panzer AM, Nielsen LB, eds. Health Literacy: A prescription to end confusion. Washington D.C. National Academies Press. doi.org/10.17226/10883.)

FIGURE 3 . Potential points for intervention in oral health literacy.

need training about the interrelationship of common risk factors of oral and general disease. Joint accreditation for interprofessional continuing education currently excludes dentistry but includes other health professions.22 Training is also needed on how to apply recommended communication techniques beginning at the undergraduate level and continuing throughout practice as new knowledge or clinical practice guidelines are created.

Further, health care facilities need to ensure their practices or clinics are userfriendly. While there are various guidelines for assessing health facilities, none exist for dental facilities. The creation of dental facility guidelines is particularly important, as the predominant site of practice has been solo private practice.

Research is needed across all aspects of oral health literacy including determining the best ways to educate the public and train provider groups as well as what messages to use, their frequency and how they are delivered (i.e., using patient health record portals, after-visit summaries, brochures or texting). The role of health literacy in integrating dental and medical practice is an issue ripe for pursuing because this approach can potentially improve oral

and general health. The 2019 National Academies of Science, Engineering and Medicine’s Health Literacy Roundtable workshop “Integrating Oral and General Health Through Health Literacy Practices” emphasized the need for research at all stages, including predoctoral interprofessional training, health system demonstration programs of various models (e.g., colocated physician and dentist practice), components of integration (e.g., effective referral practices between physicians and dentists) and the importance of developing meaningful outcome and systems measures.23 This area of research especially is needed now with Healthy People 2030’s emphasis on health and well-being. Pivotal to all research is determining the impact of improving oral health literacy on oral health and general health outcomes.

Oral health literacy is now considered a young but established field in public health dentistry and one that needs to be addressed by all federal, state and local entities by supporting it educationally, administratively and financially. We believe the Healthy People 2030 framework serves as a call to action to integrate health literacy into our plans to address the oral health objectives.

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California as Exemplar

The California Oral Health Plan 2018–2028 provides a carefully developed and targeted roadmap to improve oral health and is an example of one state’s approach to incorporate health literacy within a larger plan.24 The plan’s five overarching goals are well aligned with the Healthy People 2030 framework given the focus on prevention, health literacy, social determinants of health and engagement of multiple sectors and stakeholders. The plan is based on addressing the outcomes of a detailed assessment of the burden of oral disease and related issues that have impeded oral health improvements and emphasizes strategies that support data-driven and evidence-based interventions with broad partnership involvement. Critical assets have been secured and include funds from the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 and the Dental Transformation Initiative, part of the Medi-Cal 2020 Waiver, to improve the oral health of Medi-Cal children. Further, the plan is viewed as an essential component of the state’s Public Health 2035 vision “to reduce health care system dependence and improve health equity throughout California.”24

Conclusion

The Healthy People 2030 Foundational Principle “achieving health and well-being requires eliminating health disparities, achieving health equity and attaining health literacy” provides a call to action to incorporate health literacy interventions as an essential component of our work to eliminate health disparities and achieve health equity. This is an opportunity for those working on all topic areas including oral health. It requires integrating health literacy thinking and skills at all stages of our Healthy People planning and strategies: assessing population needs, selecting and implementing

interventions, preparing the needed workforce and evaluating outcomes. We need to establish sufficient resources to support this integration, such as toolkits for practitioners and technologies for health care systems. Additionally, we need to create collaborative, coordinated efforts with key sectors, including but not limited to businesses, media, the faith community and education, that reinforce and complement these efforts.

Our investment in oral health literacy will contribute to improved and sustained oral health and general health and well-being and can pave the way for the national collective effort to integrate health literacy to eliminate health disparities and achieve health equity. n REFERENCES 1. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. Washington, D.C. U.S. Department of Health, Education and Welfare. Public Health Service. Office of the Assistant Secretary for Health and Surgeon General; 1979. DHEW (PHS) Publication No. 79-55071. profiles. nlm.nih.gov/ps/access/NNBBGK.pdf.

2. Promoting Health/Preventing Disease. Objectives for the Nation.

Washington, D.C. U.S. Department of Education. National Institute of Education. Educational Resources Information Center (ERIC).

Department of Health and Human Services, Public Health Service.

1980. stacks.cdc.gov/view/cdc/5293.

3. Healthy People 2020: www.healthypeople.gov/2020/AboutHealthy-People. Accessed Sept. 16, 2019.

4. Centers for Disease Control and Prevention. Healthy People 2000. www.cdc.gov/nchs/healthy_people/hp2000.htm.

Accessed Sept. 16, 2019.

5. Healthy People 2010 (conference edition in two volumes).

Washington, D.C. U.S. Department of Health and Human Services.

January 2000.

6. Malvitz DM, Barker LK, Phipps KR. Development and status of the National Oral Health Surveillance System. Prev Chronic Dis 2009 Apr;6(2):A66. Epub 2009 Mar 16. PMID: 19289009.

7. Healthy People 2020 Midcourse Review: www.cdc.gov/ nchs/healthy_people/hp2020/hp2020_midcourse_review.htm.

Accessed Sept. 20, 2019.

8. Healthy People 2030 Framework. www.healthypeople. gov/2020/About-Healthy-People/Development-HealthyPeople-2030/Framework. Accessed Sept. 3, 2019.

9. The Secretary’s Advisory Committee for 2030: Committee Reports: Issue Briefs to Inform the Development and Implementation of Healthy People 2030: Health Literacy Brief. www.healthypeople.gov/2020/About-Healthy-People/ Development-Healthy-People-2030/Committee-Meetings.

Accessed Sept. 3, 2019.

10. Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition

of oral health. J Am Dent Assoc 2016 Dec;14(12):915–17. doi: 10.1016/j.adaj.2016.10.001.

11. Oral Health in America: A Report of the Surgeon General.

Rockville, Md. Department of Health and Human Services, U.S. Public Health Service, Office of the Surgeon General. National Institute of Dental and Craniofacial Research; 2000. NLM ID: 101669320.

12. Peres MA, Macpherson LMD, Weyant RJ, et al. Oral diseases: A global public health challenge. Lancet 2019 Jul;394(10194):249–260. doi: 10.1016/S01406736(19)31146-8.

13. Baiju RM, Peter ELBE, Varghese NO, Sivaram R. Oral health and quality of life: Current concepts. J Clin Diagn Res 2017 Jun;11(6);ZE21–EZ26. doi: 10.7860/ JCDR/2017/25866.10110. Epub 2017 Jun 1.

14. Kelekar U, Naavaal S. Hours lost to planned and unplanned dental visits among U.S. adults. Prev Chronic Dis 2018 Jan;15:E04. doi: 10.5888/pcd15.170225.

15. Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and performance. Am J Public Health 2011 Oct;101(10):1900–1906. doi: 10.2105/ AJPH.2010.200915. Epub 2011 Feb 17.

16. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low health literacy: Implications for national health policy. Washington, D.C.: George Washington University School of Public Health and Health Services; 2007. hsrc.himmelfarb.gwu.edu/cgi/viewcontent. cgi?article=1173&context=sphhs_policy_facpubs. Accessed Sept.

16, 2019.

17. Paasche-Orlow MK, Wolf MS. Promoting health literacy research to reduce health disparities. J Health Commun 2010;15 Suppl 2:34–41. doi: 10.1080/10810730.2010.499994.

18. Treadwell HM, Northridge ME. Oral health is the measure of a just society. J Health Care Poor Underserved 2007 Feb;18(1):12– 20. doi: 10.1353/hpu.2007.0021.

19. Young D, Weinert C. Improving health literacy with inmates.

Corrections Today 2013;75(5):70–4.

20. Kindig DA, Panzer AM, Nielsen LB , eds. Health literacy: A prescription to end confusion. Washington, D.C.: National Academies Press; 2004. doi.org/10.17226/10883.

21. National Call to Action to Promote Oral Health. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, 2003.

22. 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.org/10.17226/25468.

23. Atchison KA, Rozier RG, Weintraub JA. Integrating oral health, primary care and health literacy: Considerations for health professional practice, education and policy. Commissioned by the Roundtable on Health Literacy, Health and Medicine Division, the National Academies of Sciences, Engineering, and Medicine.

2017. www.nationalacademies.org/our-work/integrating-dentaland-general-health-through-health-literacy-practices-a-workshop.

Accessed Sept. 3, 2019.

24. California Department of Oral Health. California Oral Health Plan 2018–2028. cdph.ca.gov/Programs/CCDPHP/DCDIC/ CDCB/CDPH%20Document%20Library/Oral%20Health%20 Program/FINAL%20REDESIGNED%20COHP-Oral-Health-PlanADA.pdf. Accessed Sept. 23, 2019.

THE CORRESPONDING AUTHOR, Dushanka V. Kleinman, DDS, MScD, can be reached at dushanka@umd.edu.

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American Dental Association: Advancing Health Literacy Within and by the Dental Profession Sharon R. Clough, RDH, MS Ed

a b s t r a c t Poor oral health literacy is associated with poorer oral health

knowledge, increased dental caries severity and increased rates of patient no-show rates. The American Dental Association has made health literacy a priority since 2006 with the development of the National Advisory Committee on Health Literacy in Dentistry and an action plan to guide its work. This article summarizes the ADA’s efforts to improve the oral health literacy of the public and current and future dental professionals.

AUTHOR Sharon R. Clough, RDH, MS Ed, was the manager of preventive health activities at the American Dental Association, Council on Advocacy for Access and Prevention.

She facilitated the work of the American Dental Association’s National Advisory Committee on Health Literacy in Dentistry.

She retired in 2019. Prior to working at the ADA, she was a clinical dental hygienist, was adjunct faculty for two dental hygiene programs and was the oral health network coordinator for the Illinois Primary Health Care Association.

Conflict of Interest Disclosure: None reported.

E

ffective communication is the cornerstone of patient safety.1 There are numerous cases where ineffective communication jeopardized the health of the patient. A Hmong-speaking family was unable to communicate that their infant child, Lia Lee, was having epileptic seizures, and the physicians misdiagnosed the symptoms as pneumonia. The language barrier and difficulty with understanding the family’s cultural beliefs led to continued health issues.2 Due to a number of circumstances including access barriers and poor oral health literacy, Deamonte Driver, a 12-year-old boy from Maryland, died as a result of an infected tooth.

These and other stories offer compelling reasons for providing both written and oral information to patients that can be understood and easily acted upon.

Health literacy is defined as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”3 This also includes the educational, social and cultural factors that impact individuals’ desires and expectations and encompasses how well health care providers can meet those needs and expectations.4 The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for Healthy People 2030 includes this statement that reflects the evolution of the field: “Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.”5 The statement supports new appreciation for its multidimensionality in that health literacy is affected not only AUGUST 2 0 2 0 383

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by an individual’s abilities, but also system demands and complexities that impact the ability to access, understand and use health information and health services.5 Lack of health literacy contributes to socioeconomic and health disparities. If patients receive information they do not understand and cannot act upon, then health disparities remain a problem. Results from the 2003 National Assessment of Adult Literacy (NAAL) demonstrate the necessity for improving health literacy. The report found that only 12% of Englishspeaking adults surveyed had proficient levels of health literacy. Twenty-two percent had basic levels of proficiency and 14% had below basic health literacy skills.4 A more recent population surveillance confirmed previous NAAL findings that males, Spanish speakers and those with less education are at risk of low health literacy.6 Additionally, individuals with lower health literacy experience a greater chronic disease burden and more days of poor physical health per month than those who have higher health literacy.6 Similar to previous findings, the data from this survey showed that older adults scored below the median in health literacy; however, young adults scored below the median, indicating that health literacy is an important consideration for this age group also.6 When the discussion shifts to oral health literacy, the same concerns regarding use of health literacy skills exist. Research shows that communication between dentists and their patients plays an important role in the use of dental services.7–9 Patients with poor oral health literacy have poorer oral health, including lower levels of oral health knowledge,10,11 an increase in dental caries severity12 and an increase in the number of patient no-show rates.10 Conversely, when dental providers use good communication skills and provide clearly written instructions, oral health literacy increases, resulting in improved oral health.7–9 384 AUGUST

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The American Dental Association (ADA) policies on health literacy support clear, accurate and effective communication between the dental professional and the patient for effective dental practice and acknowledges that limited oral health literacy of patients and communication skills for health providers is a potential barrier to effective prevention, diagnosis and treatment of oral diseases.13,14 Furthermore, the ADA recognizes that improving health literacy makes patients better stewards of their own health and that of their children and supports the use of health

Individuals with lower health literacy experience a greater chronic disease burden and more days of poor physical health per month than those who have higher health literacy. literacy principles and plain language for all patients and providers for easier understanding, navigation and use of oral health information.15,16 Accordingly, written information should be written to be easily understood and formatted in such a way that the material is inviting to read. For spoken instruction, dental providers should offer information that is easy to understand and use communication strategies, such as teach-back, that confirm for the provider that the patient understands the information received.

The ADA has made health literacy a priority for over a decade. Efforts began in 2006 when the House of Delegates adopted a resolution recommended by the Council on Access, Prevention and Interprofessional Relations (CAPIR) (now called the Council on Advocacy for Access

and Prevention, CAAP) that the ADA president appoint a three-year oral health literacy ad hoc advisory committee.17 In April 2007, the National Oral Health Literacy Advisory Committee (NOHLAC), consisting of representatives from dentistry, public health, literacy and other advocacy organizations, convened at the ADA Chicago headquarters. The advisory committee was charged with developing policy recommendations, targeted educational strategies and other health programs to address oral health literacy issues. The committee developed the ADA 2010–2015 Health Literacy in Dentistry Plan, which directed their work.

The ad hoc committee met for the last time in November 2012. However, with the support of ADA Executive Director Kathleen O’Loughlin, DMD, MPH, and by the recommendation of CAAP, then CAPIR, the committee reconvened in 2014 as the National Advisory Committee on Health Literacy in Dentistry (NACHLD). To provide health information that reflects the intent of the ADA’s policies, the committee began its work by developing an updated action plan (ADA Health Literacy in Dentistry Action Plan 2016–2020).

The plan, which includes goals for advocacy, training and education, dental practice, research and coalition building, continues to provide guidance for the work of the committee.

The ADA has made substantial progress in addressing the action-plan goals and objectives with successful outcomes. These actions have brought the ADA to the forefront in being a health care association that has made great strides in establishing the organization as a health literate association. The purpose of this article is to summarize the ADA’s efforts to improve the oral health literacy of the public and current and future dental professionals.

C D A J O U R N A L , V O L 4 8 , Nº 8

Training and Educational Activities

Studies indicate that health literacy impacts effective prevention, diagnosis and treatment of oral diseases, whereas limited health literacy affects many types of health (including oral health) diseases’ outcomes and costs.18–23 Effective communication techniques by providers can make it easier for patients to follow their prescribed plan of care.20 However, research indicates that patients and health care providers, including dentists and dental hygienists, lack the necessary skills to assess patients’ literacy levels and provide information at a literacy level that is appropriate for the patient.24–27 Accordingly, continued efforts are needed to include health literacy as an element of training for current and future dental professionals.21,22,28,29 To ensure that health literacy is addressed in dental school curricula, the Council on Advocacy for Access and Prevention and its National Advisory Committee on Health Literacy in Dentistry requested that health literacy be incorporated into the Commission on Dental Accreditation (CODA) Predental Program Accreditation Standards. A definition of health literacy as well as the addition of a standard that includes health literacy was adopted

by CODA during its 2019 winter meeting. The additions to the standards were implemented in January 2020.

Oral health outcomes can be expected to be less than desired when provider/patient interactions are not clear.18 Advanced patient/provider communication skills result in improved oral health literacy for the patient, which in turn decreases patient anxiety and improves motivation and satisfaction.30,31 If students are taught the importance of good communication skills while in dental school, the likelihood that these skills will continue into professional practice following graduation is increased.30

To promote student interest about health literacy, cultivate their plainlanguage writing skills and help them become better communicators, the ADA sponsors a health literacy essay contest.

The contest began in 2015 when Sorin Teich, DMD, MBA, then assistant dean at Case Western Reserve University Dental School, requested that the ADA sponsor a contest to encourage students to become good communicators. The pilot project began with one dental school participating in the contest and has grown to include all accredited U.S.

Advanced patient/provider communication skills result in improved oral health literacy for the patient, which in turn decreases patient anxiety and improves motivation and satisfaction. dental schools. Contestants are required to complete two brief online health literacy courses offered by the Centers for Disease Control and Prevention (CDC) to increase their knowledge of health literacy and plain writing. Using the knowledge gained from the online training courses, they are assigned the task of writing an essay on a specific dental topic. Previous topics included diabetes and oral health, sweetened beverages and their effect on oral health and important things to know about baby teeth and cavities: What are they and how do we prevent them?

For the essay, students are required to provide evidence-based information that is easy for the average reader to understand. The winning essay is posted on ADA’s consumer website MouthHealthy. org. The first-place winner and four

runners-up receive cash awards. The contest is evaluated annually and changes are made based on feedback from the evaluations and on the quality of the essays submitted. The goal is to sponsor a contest that provides a true learning experience for the competing students.

Dental providers who use effective communication techniques contribute to greater oral health literacy — the patients’ ability to understand and act upon the information provided to improve their oral health.21,23 However, continued efforts are needed in educating the dental community about health literacy.24–27 Health literacy environmental scans of health center dental clinics in Maryland showed that current practices related to oral health literacy lack consistency.26,27 To provide educational opportunities for dental professionals, CAAP offers various continuing education programs at dental conferences including the ADA’s annual meeting. For those seeking immediate information, resources about health literacy are available on the ADA’s health literacy website. The website provides an overview of health literacy, information about creating a health literate environment for the dental practice and links to health literate consumer education materials.

Assessment of Dental Students’ Health Literacy Knowledge and Skills

In 2017, upon the recommendation of NACHLD, CAAP adopted a resolution to conduct an assessment of health literacy skills, practices and content from students from dental schools and allied programs.

The intent was to gain insight into dental students’ knowledge, understanding and attitudes regarding patient communication and caries prevention activities. The most recent assessment of dentists and dental hygienists skills was completed in 2008 with results for dentists published in the Journal of the American Dental AUGUST 2 0 2 0 385

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Association.26 Because there had been no recent national surveys on the topic, NACHLD recommended that a survey be conducted to assess dental students’ health literacy knowledge and attitudes.

CAAP instructed NACHLD to move forward with the survey. A workgroup consisting of NACHLD members developed and conducted the online survey during the 2018 summer semester. Dental hygiene students were surveyed during the 2019 spring semester. Increasing collaboration to advance health literacy is one of the goals of the action plan. Development and distribution efforts provided opportunities for CAAP to collaborate with other dental associations on this project. Accordingly, the American Dental Education Association and the ADA’s Council on Education and Licensure reviewed and commented on the draft survey. The ADA’s client services department, the American Student Dental Association and the American Dental Hygienists’ Association provided assistance in distributing the survey and informing faculty and students about the assessment. A data analysis is in process and results will be published with the hope that the findings will help identify gaps in education and guide curriculum development for health literacy courses for dental and dental hygiene programs.

Patient Education Materials

The average American reads at an eighth- to ninth-grade level.4 Fourteen percent of Americans have below basic health literacy.4 Despite these statistics, health information is usually written at a higher reading level (12th grade or college level) making it difficult for the average American to understand and successfully and safely act on the information in managing their own care.4,25,28 Designing clearly written patient education materials is a critical step to ensuring understanding of the health information provided.29–33 386 AUGUST

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Knowing the importance of providing clearly written information for the consumer, ADA’s product and development and sales (PDS) department hired a consulting firm to assess a few of its patient education brochures for readability and usability. Changes were made based on suggestions from the review. Ongoing training efforts continue to better prepare ADA staff who are directly responsible for writing patient education materials in order to enhance their understanding of health literacy and plain writing skills.

Periodically, PDS facilitates an advisory

Designing clearly written patient education materials is a critical step to ensuring understanding of the health information provided.

committee comprised of ADA volunteers who review and suggest edits to draft patient education brochures. To provide expertise for this endeavor, a member of NACHLD is a member of the PDS advisory committee to provide valuable insight and assistance during this process.

Conclusion

On the day he was administered the oath for surgeon general, former Surgeon General Vivek H. Murthy, MD, MBA, stated that it is necessary to “combat misinformation with clear communication” and “give the American people the best information so they can make good decisions for their own health.”34 The ADA has made substantial strides in achieving that goal. To ensure that health literacy is addressed in dental

school curricula, CAAP requested that health literacy be incorporated into the CODA Predental Program Accreditation Standards. To identify gaps in education and guide curriculum development for health literacy courses for dental and dental hygiene programs, CAAP developed and conducted a survey to assess dental and dental hygiene students’ health literacy knowledge and skills. To promote student interest about health literacy, cultivate their plain-language writing skills and help them become better communicators, the ADA sponsors a health literacy essay contest.

To provide educational opportunities for dental professionals, CAAP offers various continuing education programs at dental conferences including ADA’s annual meeting. Dental professionals seeking immediate information on the topic can easily access numerous resources on ADA’s health literacy webpage. Finally, to make certain that the ADA provides consumers clearly written dental health information, patient education materials are assessed for readability and usability and edited for clarity when needed. Acknowledging that staff cannot write clear communication if they do not have a good understanding of health literacy and plain writing skills, the ADA offers training opportunities for staff who are responsible for developing and writing patient education information.

The ADA will continue its efforts with making the association a health literate organization and improve the oral health literacy of the public and current and future dental professionals. Next steps include developing a new action plan that expands current endeavors and offers new opportunities. Suggested actions include developing a toolkit that provides health literacy resources to dental professionals, encouraging additional research on oral health literacy and identifying opportunities to collaborate with external agencies on health literacy projects. n

C D A J O U R N A L , V O L 4 8 , Nº 8

REFERENCES 1. Joint Commission. “What Did the Doctor Say?” Improving Health Literacy to Protect Patient Safety. Accessed Sept. 10, 2019.

2. Fadiman A. The spirit catches you and you fall down. New York: Farrar, Straus and Giroux; 1998.

3. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and improving oral health.

2nd ed. Washington D.C.: U.S. Government Printing Office; 2000:11–20.

4. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy (NCES 2006-483). U.S. Department of Education. Washington, D.C.: National Center for Education Statistics; 2006.

5. Federal Register. Solicitation for written comments on an updated health literacy definition for Healthy People 2030. U.S. Department of Health and Human Services. 2019 June;84(107). www.federalregister.gov/ documents/2019/06/04/2019-11571/solicitation-forwritten-comments-on-an-updated-health-literacy-definition-forhealthy-people-2030. Accessed Aug. 23, 2019.

6. Rubin D. Health literacy report: Analysis of 2016 BRFSS health literacy data office of the associate director for communication centers for disease control and prevention. www.cdc.gov/healthliteracy/pdf/Report-on-2016-BRFSSHealth-Literacy-Data-For-Web.pdf. Accessed Aug. 9, 2019.

7. Schönwetter DJ, Wener ME, Mazurat N. Determining the validity and reliability of clinical communication assessment tools for dental patients and students. J Dent Educ 2012 Oct;76(10):1276–90.

8. Sachdeo A, Konfino S, Icyda RU, et al. An analysis of patient grievances in a dental school clinical environment. J Dent Educ 2012 Oct;76(10):1317–22.

9. Horowitz AM, Kleinman DV. Oral health literacy: A pathway to reducing oral health disparities in Maryland. J Public Health Dent 2012 Winter;72 Suppl 1:S26–30. doi: 10.1111/j.17527325.2012.00316.x.

10. Sabbahi DA, Lawrence HP, LImebvack H, Rootman I. Development and evaluation of an oral health literacy instrument for adults. Community Dent Oral Epidemilol 2009 Oct;37(5):451–62. doi: 10.1111/j.16000528.2009.00490.x.

11. 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.

12. Miller E, Lee JY, DeWalt DA, Vann WF Jr. Impact of caregiver literacy on children’s oral health outcomes. Pediatrics 2010 Jul;126(1):107–14. doi: 10.1542/peds.2009-2887.

Epub 2010 Jun 14.

13. American Dental Association Policy Communication and Dental Practice (Trans.2008:454; 2013:342). Resolved, that the ADA affirms that clear, accurate and effective communication is an essential skill for patient-centered dental practice.

14. American Dental Association Policy Limited Oral Health Literacy Skills and Understanding in Adults (Trans.2006:317; 2013:342). Resolved, that the ADA recognizes that limited oral health literacy is a potential barrier to effective prevention, diagnosis and treatment of oral disease.

15. American Dental Association Policy Universal Healthcare Reform (Trans.2008:433). Resolved, that the following be

adopted as the Association’s policy on oral health care for utilization during discussions on health care reform.

16. American Dental Association. Policy Use of Health Literacy Principles for All Patients. Transactions. Chicago: 2006:322.

Resolved, that ADA supports the use of health literacy principles and plain language for all patients and providers to make it easier for them to navigate, understand and use appropriate information and services to help patients be stewards of their oral health.

17. American Dental Association. Definition of Oral Health Literacy Transactions. Chicago: 2005:322; 2006:316.

Resolved, that it is the ADA’s position that oral health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate oral health decisions.

18. Horowitz A, Kleinman D. Oral health literacy: The new imperative to better oral health. Dent Clin N Am Apr;52(2):333–44.

19. U.S. Department of Health and Human Services. National Call to Action to Promote Oral Health. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 035303, 2003.

20. Barrett SE, Dyer C, Westpheling K. Language access: Understanding the barriers and challenges in primary care settings. Perspectives from the field. McLean, Va.: Association of Clinicians for the Underserved; 2008. www.clinicians.org/ images/upload/Language_Access_Report.pdf. Accessed July 29, 2019.

21. Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance.

JAMA 2003;290(9):1157–1165. doi:10.1001/ jama.290.9.1157.

22. Parker R, Ratzan SC, Lurie N. Health literacy: A policy challenge for advancing high-quality health care. Health Aff (Millwood) 2003 Jul–Aug;22(4):147–53. doi: 10.1377/ hlthaff.22.4.147.

23. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med 2005 Apr;118(4):371–7. doi: 10.1016/j.amjmed.2005.01.010.

24. Kripalani S, Weiss BD. Teaching about health literacy and clear communication. J Gen Intern Med 2006 Aug;21(8):888–90. doi: 10.1111/j.15251497.2006.00543.x.

25. Tam A, Yue O, Atchison KA, Richards JK, BS; Holtzman JS. The association of patients’ oral health literacy and dental school communication tools: A pilot study. J Dent Educ 2015 May;79(5):530–8.

26. Rozier RG, Horowitz AM, Podschun G. Dentistpatient communication techniques used in the United States: The results of a national survey. J Am Dent Assoc 2011 May;142(5):518–30. doi: 10.14219/jada. archive.2011.0222.

27. Maybury C, Horowitz AM, Wang MQ, Kleinman DV. Use of communication techniques by Maryland dentists. J Am Dent Assoc 2013 Dec;144(12):1386–96. doi: 10.14219/jada. archive.2013.0075.

28. Nielsen-Bohlman L, Panzer AM, Kindig, DA, eds. Health literacy: A prescription to end confusion. Washington, D.C.: National Academies Press; 2004.

29. Guo Y, Logan HL, Dodd VJ, Muller KE, Marks JG, Riley JL. Health literacy: A pathway to better oral health. Am J Public Health 2014 Jul;104(7):e85–91. doi: 10.2105/ AJPH.2014.301930. Epub 2014 May 15.

30. Bress LE. Improving oral health literacy — The new standard in dental hygiene practice. J Dent Hyg 2013 Dec;87(6):322– 9.

31. U.S. Department of Health and Human Services, Office of Disease Prevention and Promotion. Plain language: A promising strategy for clearly communicating health information and improving health literacy. www.michigan.gov/documents/ mdch/LiteracyHHSarticle_205541_7.pdf.

32. U.S. Department of Health and Human Services Oral Health Coordinating Committee. U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014–2017. Public Health Reports 2016 March–April;131.

33. Brach C, Keller D, Hernandez LM, et al. Ten attributes of health-literate health care organizations. Discussion paper, Institute of Medicine Roundtable on Health Literacy, 2012. nam.edu/wp-content/uploads/2015/06/BPH_Ten_HLit_ Attributes.pdf. Accessed July 29, 2019.

34. Centers for Disease Control and Prevention. Leaders Talk About Health Literacy. “Build the Great Community,” April 22, 2015. www.cdc.gov/healthliteracy/leaders-talk-about-healthliteracy.html. Accessed Aug. 27, 2019.

THE AUTHOR, Sharon R. Clough, RDH, MS Ed, can be reached at sclough50@gmail.com.

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0057_ AA_DMMEX California CDA Update August 2020_Print ad.indd 1

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oral health equity C D A J O U R N A L , V O L 4 8 , Nº 8

Health Literacy: A Path to Oral Health Equity Homa Amini, DDS, MS, MPH, and James R. Boynton, DDS, MS

a b s t r a c t Health equity has been defined as “the absence of systematic

disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage.” 1 The social determinants of health include literacy. Health literacy, including oral health literacy, is a driver of inequity of population health. Oral health professionals have an important role to improve structural systems and interpersonal communication, working toward health equity through focus on health literacy.

AUTHORS Homa Amini, DDS, MS, MPH, is a professor of clinical dentistry, in the division of pediatric dentistry at the Ohio State University College of Dentistry in Columbus.

Conflict of Interest Disclosure: None reported.

James R. Boynton, DDS, MS, i s a clinical associate professor and pediatric dentistry division head in the department of orthodontics and pediatric dentistry at the University of Michigan School of Dentistry in Ann Arbor.

Conflict of Interest Disclosure: None reported.

W

ith the release of Healthy People 2020, the U.S. Department of Health and Human Services established the 10-year agenda for improving the nation’s health. The plan outlined four overarching goals: attainment of longer lives, elimination of disparities, creation of healthy environments and promotion of quality of life across all life stages.

These goals emphasized the concept of social determinants of health and factors that would influence health beyond one’s biology.2 The World Health Organization describes social determinants of health as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.” 3 Factors such as income, race and ethnicity, geographic location, language and education/literacy influence health outcomes more than medical care.4 These factors help explain the root causes of health disparities experienced by many populations, as

greater than 80% of health outcomes are due to socioeconomic factors, health behaviors, and the physical environment.5 The social determinants of health are the varied health-related circumstances in which people live, including housing stability, nutrition security, safety and literacy (TABLE ).6 The social determinants of health are a primary driver of health inequity. Health disparities are found in myriad of communities — African American, Hispanic, Native American, Asian, Pacific Islander, mixed race, lesbian/gay/bisexual/transgender, the disabled, military veterans and urban/ rural communities all face health inequity.7 Health equity has been defined as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage.1 Key principles underlying the concept of health equity include the following: All people should be valued equally; nondiscrimination and equality; health AUGUST 2 0 2 0 389

oral health equity C D A J O U R N A L , V O L 4 8 , Nº 8

TABLE

Examples of Social Determinants of Health6 Availability of resources to meet daily needs (e.g., safe housing and local food markets) Access to educational, economic and job opportunities Access to health care services Quality of education and job training Exposure to crime, violence and social disorder (e.g., presence of trash and lack of cooperation in a community) Residential segregation Availability of community-based resources in support of community living and opportunities for leisure-time activities Culture Social norms and attitudes (e.g., discrimination, racism and distrust of government) Transportation options Public safety Social support Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it) Language/literacy Access to mass media and emerging technologies (e.g., cellphones, the internet and social media) Legal status/immigration

is of special importance for society; individuals have rights to health and to a standard of living adequate for health; health differences adversely affecting socially disadvantaged groups are particularly unacceptable because ill health can be an obstacle to overcoming social disadvantage; the resources needed to be healthy (i.e., the determinants of health, including living and working conditions necessary for health as well as medical care) should be distributed fairly; and health equity is the value underlying a commitment to reduce and ultimately eliminate health disparities.8 Screening for the social determinants of health in clinical care settings has gained momentum. Research supports screening for social risk factors within routine clinical care as part of strategies for improving population health and reducing health inequities. There are 390 AUGUST

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various screening tools that have been developed, but there is no standardization of approaches. An example of a screening tool for social determinants of health is the self-administered Centers for Medicare & Medicaid Innovation Health-Related Social Needs Screening Tool to determine if an individual might have an unmet health-related social need. This 26-item questionnaire focuses on five core domains: housing instability, food insecurity, transportation problems, utility help needs and interpersonal safety (FIGURE ).9 The social determinants of health have a crucial bearing on health outcomes. Over the past decade, there has been great focus on the Triple Aim model developed by the Institute on Healthcare Improvement (IHI) to improve health outcomes. The model calls for simultaneous pursuit of three dimensions of health system: improving the patient experience of care (including quality and satisfaction), improving the health of populations and reducing the per capita cost of health care.10 Improving the patient experience of care and the health of populations must take into account the social determinants of health; addressing these issues would have a positive effect on health equity. Among many strategies to achieve these goals are improving the population’s health literacy.11

The Role of Health Literacy

In the 1990s, evidence began to emerge about the prevalence of low literacy in health care settings and its adverse effects on health outcomes.12 Health literacy is now recognized as an important component of health care.13 The impact of poor health literacy is broad. Low health literacy is associated with increased risks of hospitalization and death with patients with heart failure.14 Patients with low health literacy

are more likely to utilize emergency services, have less knowledge of disease management and self-report poorer health status.15 Patients with chronic kidney disease and low health literacy are at increased risk of adverse clinical events, increased health care use and mortality.16 Limited health literacy is an important factor that influences children’s asthma control and health care utilization.17 Healthy People 2020 defines health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”18 In simple terms, it refers to having the skills to navigate the health care system successfully. Health literacy is not only about education; many other skills are also important, such as speaking, listening and being able to advocate for oneself in the health system.13 Literacy levels correlate with health in adults, both in developing countries and in the U.S.19,20 Healthy People 2030’s proposed definition reflects that health literacy is not only affected by an individual’s capacity, but by accessibility, clarity and ability to act on health information and services: “Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.”21 Health literacy affects an individual’s health, health behaviors and health outcomes.22 Low health literacy, as a contributor to poorer health outcomes, is of particular concern for vulnerable populations, including children. If a parent is unable to read and comprehend instructions, prescription labels, consent forms and other information, it may lead to problems such as incorrect drug doses, improperly mixed infant formula, missed appointments and noncompliance

C D A J O U R N A L , V O L 4 8 , Nº 8

Living Situation

with immunization schedules. Parental health literacy is associated with worse asthma care measures in children, greater incidence of hospitalizations and emergency department visits and days missed from school.23 Health literacy is commonly linked to other social determinants of health. Studies have shown the rate of low literacy is significantly associated with race, ethnicity, income, educational attainment and age and is an independent risk factor even after adjustment for age, race, gender, income, education, health status and other sociodemographic variables in an array of diseases and health settings.22

Health Literacy in Dentistry

As with general health, achieving and maintaining oral health requires patients to be able to understand, interpret and act on various health information.24 Health literacy is an emerging topic in dentistry as poor oral health literacy may result in poor dental outcomes.25 Difficulty comprehending instructions, understanding preventive and home care instruction and navigating the system can make achievement and maintenance of oral health a challenge.

Although oral health in the U.S. has significantly improved since the 1960s, dental caries is the most common chronic disease of children aged 5 to 17 and is five times more common than asthma.26 With an understanding of the etiology, prevention and treatment of dental caries, it has been thought that low oral health literacy may play a role in the disease process.27 More than 50 instruments have been developed to screen for health literacy.28 These tests can alert clinicians to the possibility that a patient may have difficulty with printed materials and oral communication. Word

1. What is your living situation today? o I have a steady place to live. o I have a place to live today, but I am worried about losing it in the future. o I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station or in a park).

2. Think about the place you live. Do you have problems with any of the following?

Choose all that apply: o Pests such as bugs, ants or mice o Oven or stove not working o Mold o Smoke detectors missing or not working o Lead paint or pipes o Water leaks o Lack of heat o None of the above

Food Some people have made the following statements about their food situation.

Please answer whether the statements were often, sometimes or never true for you and your household in the past 12 months.

3. Within the past 12 months, you worried your food would run out before you got money to buy more. o Often true o Sometimes true o Never true 4. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. o Often true o Sometimes true o Never true

Transportation 5. In the past 12 months has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? o Yes o No

Utilities 6. In the past 12 months has the electric, gas, oil or water company threatened to shut off services in your home? o Yes o No o Already shut off

Safety 7. How often does anyone, including family and friends, physically hurt you?

Never (1) Rarely (2) Sometimes (3) Fairly often (4) Frequently (5) 8. How often does anyone, including family and friends, insult or talk down to you?

Never (1) Rarely (2) Sometimes (3) Fairly often (4) Frequently (5) 9. How often does anyone, including family and friends, threaten you with harm?

Never (1) Rarely (2) Sometimes (3) Fairly often (4) Frequently (5) 0. How often does anyone, including family and friends, scream or curse at you?

Never (1) Rarely (2) Sometimes (3) Fairly often (4) Frequently (5) A score of 11 or more when the numerical values for answers to questions 7–10 are added shows that the person might not be safe.

FIGURE . CMS health-related social needs screening tool9 — selected questions.

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oral health equity C D A J O U R N A L , V O L 4 8 , Nº 8

recognition tests are strongly correlated with general reading ability and reading comprehension.29 Oral health literacy can be assessed using the Rapid Estimate of Adult Literacy in Dentistry (REALD-30), a word-recognition test.30 Jones et al. examined the association of dental knowledge, dental care visits and oral health status with oral health literacy in dental patients. Patients who had incorrect dental knowledge and no dental visit in the last year and who reported having fair or poor oral health had lower REALD-30 scores than the reference group. This study concludes that a significant number of patients may have a low level of oral health literacy, which may interfere with the ability to understand oral health information.25 A study conducted on oral health literacy levels among a low-income population demonstrated differences in oral health literacy levels between racial groups. Whites were found to have significantly higher oral health literacy levels when compared to African Americans and American Indians, who have among the poorest oral health among all ethnic groups.31 Many Americans experience a mismatch between their literacy skills and the information demands that dental care places on them.32 Rozier et al. conducted a national survey to examine dentist-patient communication techniques used in the U.S.; the findings reveal that routine use of many communication techniques is low among dentists, including those techniques thought to be most effective with patients with low literacy skills.33 Parents of children enrolled in Medicaid expressed concerns that dentists do not provide the information needed to ensure good oral health for their children.34 With the growing awareness that many Americans have poor health literacy skills, effective communication becomes of paramount importance in patient 392 AUGUST

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education. Schwartzberg et al. conducted a survey of health care providers to explore the techniques used to communicate with patients faced with low literacy. Ninety-five percent of the respondents most frequently employ the communication technique of using simple language and avoiding technical jargon; 70% of respondents routinely hand out printed material to patients; and 60% of respondents read patient education material aloud. Less than 40% of the surveyed health care professionals routinely used the teach-back technique, asking the patient to state in

A significant number of patients may have a low level of oral health literacy, which may interfere with the ability to understand oral health information. their own words what they need to know or do about their health, recommended by health literacy advocates to improve patient-provider interaction. Findings of this study led to the conclusion that many providers may need specific education about low literacy and its implications for the health care system as well as training in communication techniques aimed at addressing low health literacy.35 Health literacy experts have suggested that health care providers can improve communication with patients with low health literacy by using the following techniques: slowing down while speaking to patients, using nonmedical language, showing or drawing pictures, limiting the amount of information and repeating it and using the teach-back technique.35 Research indicates that the teach-

back technique is effective, not just for improving patients’ understanding but also for improving outcomes. Patients with diabetes whose physician assessed patients’ comprehension and recall with the teachback technique had significantly better diabetes control than patients whose physicians did not use the technique.36 These techniques may be helpful for many patient conversations, as even among persons of proficient literacy, conditions such as pain or stress may negatively affect communication and understanding.

Encouraging and expecting patients to ask questions is also an effective tool to reduce the impact of limited literacy.

The National Safety Foundation’s Ask Me 3 campaign was designed by health literacy experts and encourages patients to ask the following questions: What is my main problem? What do I need to do?

Why is it important for me to do this?37 This initiative can be strengthened by having health care providers encourage and remind patients to think of questions while preparing for their visits and to focus learning around these questions.38 Following a workshop focusing on health equity and patient-centeredness, the Institute of Medicine concluded that health care providers must be able to communicate effectively with all patients, regardless of their health literacy abilities, to allow health care providers to provide patient-centered, equitable and good quality care that will help reduce the national disparities in health.39 The Centers for Medicare & Medicaid Services has also developed two goals related to health literacy as part of its quality strategy: Improve safety by teaching health care professionals how to better communicate with those who have limited health literacy and practice person-centered care and empower individuals and families through strategies that are culturally, linguistically and health literacy appropriate.40

C D A J O U R N A L , V O L 4 8 , Nº 8

Promoting Health Literacy To Advance Health Equity

Health equity was one of the six aims outlined in the 2001 Institute of Medicine report “Crossing the Quality Chasm: Health Care in the 21st Century.” The report identified six aims for improvement of the U.S. health care system: Health care should be safe, effective, patientcentered, timely, efficient and equitable — providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.41 The National Quality Forum outlined The Four I’s for Health Equity as a roadmap for promoting health equity and reducing disparities: Identify and prioritize reducing health disparities; implement evidence-based interventions to reduce disparities; invest in the development and use of health equity performance measures; and incentivize the reduction of health disparities and achievement of health equity.42 Although identification and implementation of evidence-based interventions are in the realm of the individual provider, advocacy is necessary for investment and incentives to achieve health equity. Oral health literacy has become a focus of oral health advocacy organizations and organized dentistry, with the American Dental Association advocating for national legislation HR 4678, the Oral Health Literacy and Awareness Act. The Oral Health Literacy and Awareness Act would authorize the Health Resources and Services Administration to develop a nationwide oral health literacy campaign across all of the agency’s relevant divisions to promote literacy and awareness programs that are evidence based and focused on oral health care education, including education on prevention of oral disease such as early childhood caries, periodontal disease and oral cancer.43

Health literacy improvement has increasingly been viewed as a systems issue.44 Although historically health literacy has been viewed as individual skill sets, it is evident that health care organizations, including small oral health care organizations such as a dental office, play an important role in alleviating system-level factors that impede one’s ability to make informed health care decisions. To that end, the roundtable hosted by the National Academies Roundtable on Health Literacy has developed a list of attributes to describe health-literate organizations.

Many of these system/organizational attributes can be adapted for use in the dental practice environment.

Ten attributes of a health-literate health care organization:45 1. Has leadership that makes health literacy integral to its mission, structure and operations.

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

3. Prepares the workforce to be health literate and monitors progress.

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

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

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

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

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

9. Addresses health literacy in highrisk situations, including care transitions and communications about medicines.

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

Conclusion

There have been significant improvements in the collective understanding of the impact of social determinants of health, including literacy. One’s health literacy has an important impact on health outcomes, and appropriate action can lead to improvements in health. Dentists can incorporate changes on an individual provider level, at the structural (practice) level, and advocate for system improvement at the policy level to advance health equity. n REFERENCES 1. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003 Apr;57(4):254–8. doi: 10.1136/jech.57.4.254.

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24. National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Public Health Services, U.S. Department of Health and Human Services. The invisible barrier: Literacy and its relationship with oral health. A report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent 2005 Summer;65(3):174–82. doi: 10.1111/j.1752-7325.2005.tb02808.x.

25. Jones M, Lee J, Rozier G. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc 2007 Sep;138(9):1199–1208; quiz 1266–7. doi: 10.14219/ jada.archive.2007.0344.

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37. Institute for Healthcare Improvement. Ask Me 3: Good Questions for Your Good Health. 2019. www.ihi.org/ resources/Pages/Tools/Ask-Me-3-Good-Questions-for-YourGood-Health.aspx. Accessed Nov. 30, 2019.

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39. Institute of Medicine Forum on the Science of Health Care Quality Improvement and Implementation; Institute of Medicine Roundtable on Health Disparities; Institute of Medicine Roundtable on Health Literacy. Toward Health Equity and Patient-Centeredness — Integrating Health Literacy, Disparities Reduction and Quality Improvement: Workshop Summary. Washington, D.C.: National Academies Press; 2009.

40. Centers for Medicare & Medicaid Services. (2016). CMS Quality Strategy. www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/QualityInitiativesGenInfo/ Downloads/CMS-Quality-Strategy.pdf. Accessed Nov. 30, 2019.

41. 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 Academies Press; 2001.

42. National Quality Forum. A Roadmap for Promoting Health Equity and Eliminating Disparities: The Four I’s for Health Equity. 2017. www.qualityforum.org/ Publications/2017/09/A_Roadmap_for_Promoting_Health_ Equity_and_Eliminating_Disparities__The_Four_I_s_for_ Health_Equity.aspx. Accessed Nov. 30, 2019.

43. American Dental Association. ADA supports oral health literacy legislation. www.ada.org/en/publications/adanews/2019-archive/november/ada-supports-oral-healthliteracy-legislation. Accessed Nov. 30, 2019.

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Accessed Nov. 30, 2019.

THE CORRESPONDING AUTHOR, Homa Amini, DDS, MS, MPH, can be reached at homa.amini@nationawidechildrens.org.

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PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA AUBURN & FOOTHILLS AREA: Fast growing practice in 2,500 sf w/ 6 equip. Ops, 1 add’l plumbed. 2019 GR on track to exceed $1.2M on 3 avg. Dr. days/wk. #CA632 EAST BAY: New Listing! 4 Ops, 3 Equip.

Beautiful updated digital office with 23 yrs.

Goodwill, Digital, Pano, Lasers, and Nitrous Oxide-ready. Avg 30 NP/mo. Open 4 days, CASH & PPO office! 2019 GR $614K. #CA684 EAST BAY: Central beautiful location with 4 Ops in 1,350 sf. 2019 GR $659K on only 4 doctor days/week. #CA644 FAIRFIELD AREA: 4 Ops in 1,500 sf, 30+ yrs Goodwill. Dentrix PMS, I/O Cam, Digital X-ray, paperless practice. 2018 GR $840K on 4 day/ wk. #CA655 FOLSOM/RESCUE/EDH AREA: 5 Op digital practice, modern space w/ low overhead. 2019 GR $802K. Office condo also for sale. #CA581 GREATER EL DORADO HILLS: Multidoctor practice, 3,000 sf office, 8 Ops, 7 Equip, I/O Cam, Digital X-rays & Pano. 2019 GR $2.2M. Sellers will consider working back P/T. #CA578 GREATER SACRAMENTO: Price Reduced by $50K! PPO Practice with 4 Ops, digital sensors, imaging system, I/O Cam. Practice open 33 yrs. 2017 GR $652K; Office Condo available for purchase. #CA561 GREATER SACRAMENTO: Great area w/ 38 yrs Goodwill. 4 Ops in 1,100 sf. 2018 GR of $1M+ on 32 hrs/wk. #CA656 LAKE TAHOE AREA ENDO PRACTICE: 3 Ops, 3 digital sensors, Cone Beam in 1,100 sf.

Consistent GR $525K for the last three years on 32 avg. Dr. hrs/wk. #CA602 LAKE TAHOE AREA: GP practice with 5 Ops w/ 6th Open, Operatory views of Lake Tahoe, only 34 Delta Premier patients, 2,100 sf.

2019 GR $579K on 22 avg. Dr. hrs/wk. #CA608 MENLO PARK: New Listing! 4 Ops, rare opp in desirable area, Digital, Itero Scanner, Paperless, 6 hyg days 2019 GR $1M+. #CA686 MONTEREY: 4 Ops, Seller Financing Available to right buyer! Dentrix, strong Hyg program, Below Market Asking Price. 2019 GR $930K. #CA690 MONTEREY: 4 Op, 1,600 sf in highly desirable area with plenty of free parking. 2018 GR $1M+ on 32 hrs/wk. #CA650 NORTHERN CA PEDO PRACTICE: Large practice in downtown location, 5,000 sf with 7 equip Ops, 2 add'l plumbed. 2018 GR $3M+. #CA658 REDDING AREA: New Listing! 6 Ops, Dentrix, Digital, 8 hyg days/mo. PPO/Cash.

Motivated seller, low asking price. #CA668 REDDING AREA: Modern practice in 1,600 sf with 4 equipped Ops, 1 additional plumbed.

2019 GR $558K on 32 hrs/wk. #CA648 ROCKLIN/LINCOLN AREA: 10 Ops, 6 equip, 4 plumbed,. 2,619 sf. Growth potential in all Specialties, 2018 GR $747K on 4 days/wk. #CA641 SACRAMENTO: New Listing! 5 Ops, 4 Equip.

50+ yrs. Goodwill. Digital, CBCT, New computers, 2019 GR $434K (seller took 3 mo. off) #CA678 SACRAMENTO: Price Reduced $70K! Hi-traffic location, Digital, Room to grow as specialties referred out. #CA590 SACRAMENTO: Northern area, 50+ yrs.

Goodwill, 3 Ops +1, Digital, Paperless, Digital Pano. Specialty referred out. 2019 GR $616K. #CA667

SACRAMENTO AREA: Price reduced by $100K! GP & Specialty HMO/some PPO Practice.

9 Ops, I/O Cam, Digital Pano. 2017 GR $1.1M+, 2018 Quickbooks (to be verified) GR $680K. 5,000 sf bldg. avail. #CA567 SAN FRANCISCO FACILITY ONLY: 3 Ops in the heart of the city! Leasehold and equipment only, low rent. Asking $125K. #CA677 SAN FRANCISCO: Low Rent! 30+ yrs Goodwill.

Beautiful 4 Op office w/ strong hyg program. 2019 GR $740K+. #CA657 SAN JOSE: 3,150 sf with 10 Ops, 6 Equip. Great cash flow, beautiful retail space with hi-traffic and visibility. 2018 GR $998K. #CA600 SAN JOSE: New Listing! 6 Ops, Paperless, Digital, CAD./CAM, Digital Pano. Seller will stay on P/T, if desired. 2019 GR $1.3M+. #CA1140 SONOMA COUNTY: 2018 GR $906K. 1,000 sf, 3 Ops w/ opportunity to expand. Paperless, Dentrix, Digital, I/O Cam. Selling both Practice and portion of dental building ownership. #CA594 SONOMA COUNTY: Large GP, 2018 GR above $2.8M. Stand-alone 3,000 sf prime Real Estate, 72 NP/mo.10 hyg days. 6 Ops, Pano X-ray, Dexis, Cameras, Laser, Dentrix. Both Business & Real Estate for sale or Lease. Doctor Retiring. #CA544 SONOMA COUNTY: 2018 GR $2M+. 8 Ops in 4,600 sf, 13 hyg days on 4½ day/wk. 42 yrs Goodwill. Doctor retiring and will work back.

Paperless, Digital, hi-tech, modern. #CA601 VACAVILLE AREA: Centrally-located & hitraffic location with 25+ yrs Goodwill. 5 Ops in 1,700 sf. 2019 GR $556K on 32 hrs/wk. #CA645 VALLEJO: 4 Ops, 1,650 sf w/ below-market rent. 2019 GR $791K, 4 hyg days/wk, low OH. #CA469

CENTRAL CALIFORNIA CENTRAL COAST: New Listing! 5 Ops, digital, 25+ yrs. Goodwill. Newly renovated, the practice sees 30 NP/mo. Strong hyg program. Beautiful Central Coast Location. 2019 GR $1.1M+. CA1218 CENTRAL COAST, NIPOMO: New Listing!

5 Ops, perfect opportunity for start-up with a smalltown feel. Walk in and start seeing patients, dental software and digital x-rays are already in place. All reasonable offers will be considered. #CA1208 CENTRAL VALLEY PEDO PRACTICE: Shared space w/ Ortho, 7 Op, 3,800 sf. 2019 GR $610K as part-time practice. Great starter practice or satellite office. #CA660 FRESNO AREA: GP and Prosthodontic Practice prime for a GP to purchase. 4 Ops, 1,500 sf, Digital Sensors, film Pano, DentalMate Software, attractive office bldg. 2018 GR $386K. #CA588 GREATER FRESNO: New Listing! 4 Ops, Digital, PPO/Denti-Cal, fast-growing area, 22 yrs.

Goodwill, Digital. Bldg avail to purchase. #CA676 GREATER FRESNO AREA: Great location for well-established practice with 40+ yrs Goodwill. 6 Ops, Digital X-ray, Diamond Dental PMS. 2018 GR $638K. #CA621 MADERA: Modern 4 Op (room for 5th) PPO and Denti-Cal practice with newer equipment, 1,800sf, and GR $233K on 2 Dr. days/week. Building facility also available for purchase. #CA542 MERCED AREA: 30+ yrs Goodwill in great location. 4 Ops, Dentrix, Digital, I/O Cam, Laser, Pan/Ceph. 2018 GR $691K. #CA642 MODESTO AREA: Established neighborhood with 60+ yrs Goodwill. 5 Ops, 1,450 sf. 2018 GR $1.1M+ on 3 day/wk. Dental Condo also available for purchase or lease. #CA635 STOCKTON AREA: Great opp to purchase practice and bldg, 3,000+ sf with 6 Ops, good hyg recall. 2018 GR $1M+ on avg 37 hrs/wk. #CA616

Northern California Office

1.800.519.3458

Henry Schein Corporate Broker #01230466

SOUTHERN CALIFORNIA BAKERSFIELD: Well-established, 5 Ops, 4 Equip. In-house dental lab. Condo also for sale.

2019 GR $363K on 3 days/wk. #CA674 COASTAL ORANGE COUNTY: 3 Ops, Steps from the beach, CEREC, Digital, CBCT, Microscope. Priced to sell. 2019 GR $169K. #CA683 COASTAL ORANGE COUNTY: 5 Ops, Nicely appointed, long-term staff, Specialty referred. 2019 GR $456K. #CA679 COVINA: New Listing! 4 Ops, 67 years in location, 22 with seller. Strong hyg prog, room to grow w/specialties. 2019 GR $804K. #CA692 DIAMOND BAR: Beautiful, 5 Ops in Prof.

Bldg., Digital, Dentrix, Must-see, call for an appointment. #CA672 GARDENA: New Listing! Ready to retire! 7 Ops, real estate for sale also. 50% Denti-Cal, some HMO and PPO. 2019 GR $568K. #CA1050 HUNTINGTON BEACH: 5 Ops, desirable location, Digital, Strong hygiene program. 2019 GR $604K. #CA685 HUNTINGTON BEACH: 4 Ops, located in a busy retail center with great visibility. Practice utilizes Digital X-rays and Easy Dental PMS. 2019 GR $466K. #CA673 EL CENTRO: Great location with low rent. 4 Ops, 3 Equipped, Digital, 25 Yrs Goodwill.2019 GR $850K. #CA680 INLAND EMPIRE: 2 Dental Offices next to each other, One GP, One Ortho/Pedo. Digital, 13 Ops total. GR $850K. #CA681 INLAND EMPIRE: 4 Ops, Across from busy hospital. Digital, Real Estate also for sale. 2019 GR $432K. #CA682 LOS ALAMITOS: Beautiful state-of-the-art practice with 4 Ops, and mostly associaterun. Digital, cash and PPO in a great location.

GR $900K w/ $390K Adj. Net. #CA662 LOS ANGELES: Price Reduced! West Side, 5 Ops, 4 Equip, EagleSoft, Digital, 40 yrs Goodwill, 2019 GR $610K. #CA640 LOS ANGELES: Near Glendale, 4 Ops in standalone bldg w/ great visibility. Low rent and $6K/ mo. CAP check. Room to grow! GR $200K+ with low OH. #CA665 NORTH ORANGE COUNTY: 5 Ops, open since 1965. Dentrix, digital Pano. Retiring seller will assist w/ smooth transition. One-story prof. bldg. 2018 GR $231K. Room to grow. Most Specialty procedures referred out. #CA558 ORANGE COUNTY: 5 Ops, Beautiful office, Digital, Paperless, hi-traffic area with great signage and low-rent. 2019 GR $501K. #CA670 PALM SPRINGS AREA MULTISPECIALTY: Priced to sell @ $775K! 5 Ops, lecture room, 28 yrs Goodwill. Hi-end, mostly cash patient base. Dentrix, Digital, CT Scan & Gemini Dual Wave Laser. History of $1.2M+/yr on 4 days/wk. #CA604 SAN FERNANDO VALLEY: 10 Ops, 8 Equip, hi-tech, fantastic location. Digital, Pano, CT Scan.

GR $1.1M+. #CA664 SAN GABRIEL VALLEY: 4 Ops, Digital X-rays, 65 yrs Goodwill. Most specialty work referred out, most PPO plans are accepted. Busy road with great visibility, open 4 days/wk. Nicely appointed; excellent opportunity. #CA596 SHERMAN OAKS: 5 Ops, 4 Equip, 44 yrs goodwill. Nicely appointed in high-end bldg.

Strong hygiene program, Specialty work referred, room to grow. Legacy practice. 2019 GR of $940K. #CA688

www.henryscheinppt.com

SOUTH ORANGE COUNTY PERIO: 4 Ops, 3 Equip, Coastal Community, Modern, Busy strip center location near hi-end residential. 2019 GR $845K. #CA643 SO CAL DESERT AREA: New Listing! 4 Ops 27 yrs. Goodwill. Strong hyg prog w/ hi-end patient base. 2019 GR $809K. #CA691 SOUTH BAY/LONG BEACH AREA: Family practice est. in 1950. 3 Ops, Digital, Strong hyg program. Great area. 2019 GR $651K. #CA671 WEST COVINA: State-of-the-art practice with 3 Ops and is all digital and modern with 1 day of Hygiene/wk. 2019 GR $1.2M+ with Adj. Net of $420K in a great location with low rent. #CA661

SAN DIEGO ENCINITAS: 4 Ops. Busy retail center.

Remodeled 5 yrs. ago with new equipment.

Dentrix, Digital, Pano, and Laser. 4 hyg days/wk.

2018 GR $813K. #CA574 LA JOLLA: UTC Area, Leasehold with patients.

7 Ops Digital in retail center with strong anchors.

Priced to sell! #CA663 NORTH COUNTY: New Listing! 5 Ops, 46 yrs.

Goodwill, Dentrix, Digital, E4D, strong hyg. program, most specialty referred. 2019 GR $1.1M+. #CA689 POWAY: New Listing! 4 Ops, priced for quick sale! Desirable strip mall location. Digital, clean and modern. GR $264K. #CA1111 POWAY: 3 Ops, located in a busy strip center w/ room to grow! Digital X-rays, I/O Cam, Pano, and Laser. 2018 GR $226K. #CA659 SAN DIEGO: New Listing! 7 Ops, 5 Equipped, located in a large retail center. EagleSoft, PPO/ Cash, 3 year average collections of $509K. #CA687 SAN DIEGO COUNTY ORTHO: Rare Opportunity in the San Diego County area, Established office with updated computer hardware. Paperless with many years of goodwill.

Excellent location. This will sell quickly. #CA615

OUT OF CALIFORNIA CENTRAL COAST, OREGON: Minutes to the ocean. 3 Dr. days/wk, 2 hyg days/wk. 2019 GR $404K, positioned for growth, Doctor is retiring. #OR112 SOUTHWEST PORTLAND: 7 Ops, 6 Equip, Dentrix, Digital, Pano. Well-maintained leased space. 2019 GR $598K. #OR115 BURIEN AREA, WA: New Listing! 3 Ops, Busy Area. Very low overhead and good cash flow.

Could relocate in Bldg to bigger suite. #WA102

Southern California Office

1.888.685.8100

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Improving Oral Health Literacy in California: A Perspective Jayanth Kumar, DDS, MPH

AUTHOR Jayanth Kumar, DDS, MPH, is the California state dental director. He is a board-certified specialist in dental public health and a former director and president of the American Board of Dental Public Health.

Conflict of Interest Disclosure: None reported.

D

uring the past century, the oral health of Americans improved significantly as a result of healthy behavior, improved access to care, great strides in research and practice and the adoption of community water fluoridation across the country. In spite of this, dental caries remains the most common childhood disease and disparities in oral health are widespread. Although the knowledge exists to prevent and manage oral health diseases, it has been difficult to translate into effective, real-world practice. Current research indicates that improving oral health literacy will be critical to advance oral health for all. Oral health literacy is defined as the capacity to obtain, process and understand basic oral health information needed to make appropriate health decisions and has been a focus of many national and state efforts to improve oral health. The 2000 surgeon general’s report “Oral Health in America” concluded that improving oral health requires educating the public, providers and policymakers about science-based interventions that prevent oral diseases.1 The 2011 Institute of Medicine report “Advancing Oral Health in America” found that the public lacked understanding about how to prevent and manage oral diseases and how to navigate the oral health system.2 The report recommended that all relevant agencies of the Department of Health and Human Services undertake health literacy and education efforts aimed at individuals, communities and health care professionals. This included recommendations to enhance professional

education on best practices in patientprovider communication skills with a focus on how to communicate to an increasingly diverse population about prevention of oral cancers, dental caries and periodontal disease. The 2011 California Dental Association Access Report suggested that raising the dental IQ of all Californians should be a core principle for every health care provider in every program and setting.3 In California, the percentage of the population aged 16 and older that lacks basic prose literacy skills varied from a low of 6.7% in Placer County to a high of 41.5% in Imperial County.4 Such low literacy will likely impact oral health literacy. According to the Centers for Disease Control and Prevention, nine out of 10 adults struggle to understand and use health information when it is unfamiliar, complex or jargon-filled.5 Several factors, such as poverty, education, race/ethnicity, age and disability, are associated with lower health literacy skills. Although health literacy skills are needed for all populations, some of the greatest disparities in health literacy occur among racial and ethnic minority groups from different cultural backgrounds and those who do not speak English as a first language.6 The 2017 report “Status of Oral Health in California: Oral Disease Burden and Prevention” concluded that oral diseases are highly prevalent in all stages of life among California residents.

Further, these diseases are correlated with socioeconomic factors such as income, race and ethnicity and educational attainment.

Although effective preventive measures are available, both clinical dental services AUGUST 2 0 2 0 397

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and community-level interventions are underutilized. To improve oral health over the course of the next 10 years, the California Department of Public Health published the California Oral Health Plan 2018–2028 that provides a roadmap for all Californians.7 It presents a framework for addressing the oral disease burden and the disparities in local communities and statewide. The framework is built with six focus areas: determinants of health, utilization of dental services, infrastructure, capacity and payment systems, communication strategies and surveillance and evaluation.

Over the past two years, the California Office of Oral Health has supported oral health programs in 59 local health jurisdictions (LHJs) through funding from the California Healthcare, Research and Prevention Tobacco Act of 2016 to conduct needs assessments, identify resources and assets and develop oral health programs. Thirty-one out of 35 LHJs that have approved oral health improvement plans as of December 2019 identified the priority to educate the public and professionals in their communities about improving oral health. The California Oral Health Plan recognizes that social, economic and physical environments influence health and risks that are common to many chronic diseases, including oral diseases.

Addressing factors such as education, poverty, housing and transportation will require broader societal actions, but steps can be taken by the oral health community to mitigate the effects of these determinants of health through policies and programs that encourage healthy habits, self-management, dental insurance benefits, timely dental assessments, preventive measures and prompt quality, evidence-based dental care. For these interventions to be effective, information needs to be communicated in such a 398 AUGUST

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way that it helps people make healthier decisions. Recognizing this, the California Oral Health Plan has set an objective to increase the proportion of patients (and caregivers) who report that their dental care teams give them easy-to-understand instructions about what to do to take care of their oral health and how to prevent or treat oral diseases. This is aligned with the current working definition proposed by the National Health Promotion and Disease Prevention Objectives for 2030 that states health literacy occurs when a society provides accurate health

The California Oral Health Plan recognizes that social, economic and physical environments influence health and risks that are common to many chronic diseases, including oral diseases. information and services that people can easily find, understand and use to inform their decisions and actions.8 Therefore, dental professionals can play a key role in increasing oral health literacy and recommended oral health practices through communitywide messages and providerpatient communication in dental offices.

A national survey of dentists found low routine use of 18 communication techniques thought to be important in promoting patient and caregiver health literacy.9 These techniques included creating a patient-friendly practice, using simple language, limiting the number of concepts presented, showing pictures or models and incorporating “teach-back.”

“Teach-back” (or “teach-to-goal”) is considered an especially effective technique in which the health provider asks the

patient or caregiver to summarize in their own words the key points about their health condition and what actions they will take. The University of California, Berkeley, Health Research for Action Center recently conducted a study about oral health literacy needs of dental professionals and resources available to them. The report concluded: “Although health care providers may know what messages they need to communicate to patients and parents/caregivers (i.e., what patients should do and not do), most lack training and skills on how to communicate effectively to ensure concise, culturally sensitive, educationally appropriate, bidirectional, motivational and supportive communication to engage and empower patients to care for their own and their children’s oral health.10 The American Dental Association has proposed an ambitious oral health literacy action agenda that includes advocacy, training of dental providers and creation of health-literate oral health resources.11 To make progress toward this agenda, a number of initiatives are underway in California. The Office of Oral Health has contracted with the Health Research for Action Center to conduct trainings and create materials for an oral health literacy toolkit for dental teams and practices to improve uptake of information about oral health literacy. The ADA National Advisory Committee on Oral Health Literacy is providing input on toolkit development with the expectation that these resources can be adapted for use nationally. This will help dental professionals assess the patient-friendliness of their practices and find ways to make their practices “more health literate,” especially for lower literacy patients and families. The toolkit will include information on oral health literacy and specific communication strategies including plain language communication,

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the teach-back method and creating a shame-free and welcoming clinical environment. In addition, the California Oral Health Technical Assistance Center at the University of California, San Francisco has created resources for local health departments and dental practitioners to promote kindergarten oral health assessment, water fluoridation, school-based/linked programs and tobacco cessation counseling. The Medi-Cal (Medicaid) Dental Program has launched “Smile, California,” a campaign to increase members’ use of Medi-Cal’s dental benefit.12 It is intended to educate eligible members about the services available to promote oral health and make it easier for members to access care. The California Dental Association (CDA) expressly used its dental care event, CDA Cares, to educate the public and policymakers on the importance of good oral health and access to dental care. Additionally, CDA has developed an online course, Treating Young Kids Every Day, which instructs dental professionals on how to engage families in daily activities to prevent the initiation of dental disease in very young children. Dental professionals are encouraged to use these resources to support patients’ efforts to improve their oral health. By using these oral health literacy strategies and practices, we at the Office of Oral Health are hopeful that the dental office environment will be easier to navigate, patients’ adherence to their recommended treatment plan will be higher and improved health outcomes will be achieved. n

Washington, D.C.: The National Academies Press; 2011.

3. California Dental Association. Phased Strategies for Reducing the Barriers to Dental Care in California. California Dental Association Access Report; 2011.

4. County Health Rankings and Roadmaps. Illiteracy.

Percentage of population age 16 and older that lacks basic prose literacy skills. www.countyhealthrankings.org/app/ california/2012/measure/factors/66/data?sort=sc-2.

5. Centers for Disease Control and Prevention. www.cdc.gov/ healthliteracy/shareinteract/TellOthers.html.

6. U.S. Department of Health and Human Services. Healthy People 2020. Health Literacy. www.healthypeople.gov/2020/ topics-objectives/topic/social-determinants-health/interventionsresources/health-literacy.

7. California Department of Health. California Oral Health Plan 2018–2028. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/ CDCB/Pages/OralHealthProgram/OralHealthProgram.aspx.

Accessed Dec. 5, 2019.

8. U.S. Department of Health and Human Services. Solicitation for Written Comments on Updated Health Literacy Definition for Healthy People 2030. www.federalregister.gov/ documents/2019/06/04/2019-11571/solicitation-for-

written-comments-on-an-updated-health-literacy-definition-forhealthy-people-2030.

9. Rozier RG, Horowitz AM, Podschun G. Dentist-patient communication techniques used in the United States. The results of a national survey. J Am Dent Assoc 2011;142(5):518– 530. doi: 10.14219/jada.archive.2011.0222.

10. University of California, Berkeley, Health Research for Action Center. Promoting oral health literate practice in dental team providers: Knowledge of oral health literacy, use of communication strategies and improving uptake at dental practice sites, and environmental scan of training resources on oral health literacy for health care providers and review of selected oral health education materials for patients. Technical reports submitted to the Office of Oral Health. October 2019.

11. American Dental Association. Health Literacy in Dentistry Strategic Action Plan 2010–2015.

12. Smile, California. smilecalifornia.org/about. Accessed Dec. 5, 2019.

THE AUTHOR, Jayanth Kumar, DDS, MPH, can be reached at jayanth.kumar@cdph.ca.gov.

ACKNOWLEDGMENT The author thanks Linda Neuhauser, DrPH, MPH, clinical professor, School of Public Health, University of California, Berkeley, for her helpful suggestions.

REFERENCES 1. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services; 2000.

2. Institute of Medicine. Advancing Oral Health in America.

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National Academies of Sciences, Engineering and Medicine: Dentistry’s Valuable Investment in the Health Literacy Roundtable Lindsey A. Robinson, DDS

AUTHOR Lindsey A. Robinson, DDS, h as 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.

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T

he National Academies is an independent, nonprofit organization dating back to the presidency of Abraham Lincoln in 1863 when he signed a congressional charter establishing the National Academy of Sciences (NAS) to provide decision-makers in government and the private sector with unbiased and authoritative evidence.

The NAS expanded in 1964 with the creation of the National Academy of Engineering and again in 1970 with the addition of a health science arm, originally branded as the Institute of Medicine (IOM). This branding was officially retired in 2015 when members of the National Academies voted to change the name to the National Academy of Medicine (NAM) as part of an overall internal realignment to better capture the multidisciplinary nature of the scientific research enterprise.

Each year, more than 3,000 individuals, members and nonmembers volunteer their time, knowledge and expertise to advance the nation’s health through the work of the NAM. The National Academies receives no congressional appropriations directly, but approximately 70% of their funding comes from federal

agencies who request independent, evidence-based studies from them. The remainder of the funding is provided by organizations, industry, foundations and gifts from individuals. In its advisory capacity, the NAM convenes consensus committees in addition to hosting workshops, roundtables and a variety of activities that facilitate multidisciplinary discussion and catalyze action to improve the health of people around the world.

Health Literacy Roundtable

The Roundtable on Health Literacy was established in 2005 to build upon the work of the IOM consensus report “Health Literacy: A Prescription to End Confusion,” which was published in 2004. According to the report, health literacy is defined as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”

The field has received much national attention over the past decade and is now widely understood as playing a crucial role in efforts to improve the public’s health. In 2000, it became a national health care priority with its inclusion as a Healthy People (HP) 2010 goal,

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and in 2003, then Surgeon General Richard Carmona stated that “health literacy can save lives, save money and improve the health and well-being of millions of Americans.” With the recent release of HP 2030, health literacy is for the first time intertwined in the foundational principles and overarching goals of the HP initiative.

The Roundtable is composed of a group of leaders from diverse backgrounds who share an interest in health literacy and whose sponsoring organizations are willing to fund a seat for the purpose of furthering advances in the field. Current sponsoring organizations include Pfizer, Merck, the National Library of Medicine, Northwell Health, Health Literacy Media and the Health Resources and Services Administration.

The Roundtable convenes public workshops that facilitate discussions on challenges facing health literacy practice and identifying approaches to promote health literacy through mechanisms and partnerships in both the public and private sectors.

Workshops are available for all to attend at no charge either in person or by webinar, and published proceedings can be downloaded for free from the National Academies’ website.

The Roundtable vision is of a society in which the demands of the health and health care systems are respectful of and aligned with people’s skills, abilities and values thereby improving the quality and value of health care and individual and community well-being. The mission of the Roundtable is to inform, inspire and activate a wide variety of stakeholders to support, develop, implement and share evidence-based health literacy practices and policies to improve the health and well-being of all people.1

In March 2012, the Roundtable convened the first workshop on oral health. I was asked to be a presenter on California’s state activities in oral health literacy.2 The following year the California Dental Association (CDA) was invited to be a sponsoring organization and the CDA Board of Trustees agreed to provide funding for a seat in view of existing policy in support of oral health literacy. I had the great honor to be appointed as CDA’s representative.

The Roundtable vision is of a society in which the demands of the health and health care systems are respectful of and aligned with people’s skills, abilities and values.

In 2015, the funding responsibility was transferred to the ADA as part of the Council on Advocacy for Access and Prevention activities to support oral health literacy and the National Advisory Committee on Health Literacy in Dentistry (NACHLD). Funding for the seat reverted back to CDA in 2018 and the ADA retained financial support for NACHLD. A member of NACHLD, Nicole Holland, DDS, MS, from Tufts University School of Dental Medicine, was chosen last year by the National Academies to join the Health Literacy Roundtable as an academic member. These invited members bring no funding but are valuable individuals who bring content expertise and research experience to the Roundtable’s work.

Oral Health Collaborative

In 1995, an IOM report, “Dental Education at the Crossroads: Challenges and Change,” recommended greater integration of dentistry with the larger health care system. One of the four objectives presented was to “promote attention to oral health (including the oral manifestations of other health problems) not just among dental practitioners but also among primary care providers, geriatricians, educators and public officials.” The medical and dental care systems in the United States historically have operated in parallel if not separate universes. In most cases, they have different education systems, accreditation bodies, licensure oversight, financing mechanisms, clinical care locations and professional organizations. These systems have been structured with little acknowledgment that diseases in the mouth and in the rest of the body can affect each other.

Without a supporting infrastructure, patients and consumers have been left on their own to recognize the need and make connections between medical and dental care. The increasing amount and complexity of scientific knowledge for health promotion, disease prevention and care and impact from social determinants known to affect health further the challenges faced by many people. A growing number of diverse organizations and groups are advocating for the integration of medicine and dentistry, especially for patients with chronic diseases such as diabetes.

There is now a significant body of evidence demonstrating a correlation between the provision of periodontal care for these patients and better medical management of their disease.

In 2015, a few Roundtable members, including me, established an AUGUST 2 0 2 0 401

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action collaborative to explore ways in which health literacy principles and practices can promote effective integration of oral health and general health into an actionable primary care model, and additionally, to bolster opportunities and mitigate challenges related to integrating dental health and general health in the primary care setting. We invited two outside experts, Alice Horowitz, PhD, from the University of Maryland and David Gesko, DDS, from Health Partners in Minnesota, to join us in creating a statement of task and outline of activities to guide our work. A primary goal was to convene a workshop under the umbrella of the NAM to highlight the critical need to merge the mouth back into the body.

The collaborative commissioned an environmental scan of existing programs and practices that integrate oral and general health. The ADA provided a small grant to augment funding from the Roundtable to commission the paper from three distinguished authors, Kathryn Atchison, DDS, MPH, from the University of California, Los Angeles, and Gary Rozier, DDS, and Jane Weintraub, DDS, MPH, both from the University of North Carolina.3

Integrating Oral and General Health Through Health Literacy Practices: A Workshop

In the spring of 2018, the Roundtable put together a planning committee to develop an agenda, define specific topics to be addressed and select and invite presenters for the workshop using the commissioned paper as the guiding element. The committee was composed of national thought leaders in the fields of academics, research, policy, health care management and ethics as they relate to the subject 402 AUGUST

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being explored. The intended audiences for the workshop and proceedings were the Roundtable, health literacy professionals, health practitioners and institutions, oral health practitioners and institutions, policymakers, media and the general public. To augment institutional funding for the workshop, generous contributions were made by the ADA, the Dentaquest Foundation, the National Institute of Dental and Craniofacial Research, the American Association of Dental Research, the American Dental Education Association

In the eyes of Roundtable members, the commissioned paper remains as one of the best ever received, and in 2020, is still one of the most frequently downloaded from the website. and the Health Resources and Services Administration. The one-day workshop was convened on Dec. 6, 2018, at the National Academies’ Keck Center in Washington, D.C. This public event included presentations and discussion of integrating oral health, primary care and health literacy; health literacy and care integration; exploring pathways to integration; and developing a research agenda for integration. The workshop proceedings were released in July 2019 by the National Academy Press both online and in hard copy following institutional guidelines.4 In the eyes of Roundtable members, the commissioned paper remains as one of the best ever received, and in 2020, is still one of the most frequently downloaded from the website.

Both the ADA and CDA have made valuable contributions to furthering the field of health literacy in dentistry.

CDA’s investment in the Roundtable is greatly appreciated by the National Academies, allowing dentistry’s direct involvement in a highly regarded national, nongovernmental entity with significant policy influence and brings a valuable voice in supporting efforts to educate the broader health community about the value of oral health. Prevention has always been the cornerstone in the practice of dentistry. Prevention is enhanced when health literacy principles are at the core of communication and a shared understanding exists between provider and patient that promotes good self-management skills. The commissioned paper, workshop proceedings and continuing support of the Roundtable will catalyze new opportunities for working in concert with our medical colleagues to improve the health of the nation. n REFERENCES 1. The National Academies of Sciences, Engineering and Medicine. Roundtable on Health Literacy. www. nationalacademies.org/our-work/roundtable-on-health-literacy.

2. Institute of Medicine. Oral health literacy: Workshop summary.

Washington, D.C.: The National Academies Press; 2013.

3. Atchison KA, Rozier RG,Weintraub JA. Integrating Oral Health, Primary Care and Health Literacy: Considerations for Health Professional Practice, Education and Policy.

4. The National Academies of Sciences, Engineering and Medicine. Integrating oral and general health through health literacy practices, proceedings of a workshop. www.nap.edu/ download/25468.

1.

Can I get all cash for the sale of my practice?

2.

If I decide to assist the Buyer with financing, how can I be guaranteed payment of the balance of the sales price?

3.

Can I sell my practice and continue to work on a part time basis?

4.

How can I most successfully transfer my patients to the new dentist?

5.

What if I have some reservation about a prospective Buyer of my practice?

6.

How can I be certain my Broker will demonstrate absolute discretion in handling the transaction in all aspects, including dealing with personnel and patients?

7.

What are the tax and legal ramifications when a dental practice is sold?

QUESTIONS MOST OFTEN ASKED BY BUYERS: 1.

Can I afford to buy a dental practice?

2.

Can I afford not to buy a dental practice?

3.

What are ALL of the benefits of owning a practice?

4.

What kinds of assets will help me qualify for financing the purchase of a practice?

5.

Is it possible to purchase a practice without a personal cash investment?

6.

What kinds of things should a Buyer consider when evaluating a practice?

7.

What are the tax consequences for the Buyer when purchasing a practice?

Lee Skarin & Associates have been successfully assisting Sellers and Buyers of Dental Practices for nearly 30 years in providing the answers to these and other questions that have been of concern to Dentists.

Call at anytime for a no obligation response to any or all of your questions Visit our website for current listings: www.LeeSkarinandAssociates.com

LEE SKARIN & ASSOCIATES INC.

QUESTIONS MOST OFTEN ASKED BY SELLERS:

Offices:

805.777.7707 818.991.6552 800.752.7461 CA DRE #00863149

Specializing in selling and appraising dental practices for over 46 years!

Kern, Santa Barbara & Ventura County

Los Angeles County COVINA—O.S. practice with 60 yrs of goodwill. Grossed $476K in 2019. ID #5327.

SANTA MARIA— GP located in a single story free standing bldg with 11 eq ops. 73 yrs of goodwill. Grossed $2.5M in 2019.

Buyer’s net of $636K. ID #5325.

CUDAHY— GP w/ 4 eq ops in a shopping center. Grossed $429K in 2019. ID#5328.

DUARTE— GP established in 1964 located in a 2 story mixed bldg. Grossed approx. $350K in 2019. Property ID #5183.

SIMI VALLEY— GP w/ 54 years of goodwill in free standing building. Grossed approx. $575K for 2019. NET $185K. ID #5294.

GLENDALE—GP w/ 3 eq ops and 1 plmbd not eq op in a 3 story medical professional bldg. Grossed approx. $544K in 2019. Property ID #5305.

VENTURA - GP w/ 4 eq ops . PPO & Cash only. 40 years goodwill. Projection approx. $470K in 2019. Property ID #5288.

GLENDALE—Turn-Key GP WITH 3 eq. ops and 1 plmbd not eq in a 2 story building.

Grossed $376K in 2019. Property ID 5320.

Orange County ANAHEIM— GP located in a small shopping center. Has 4 eq ops w/ digital x-ray. Approx. 40-45 new patients/mo. Grossed approx. $1.35M in 2019. Net $876K. Property ID #5296.

GRANDA HILLS— With 50 yrs of goodwill this general practice grossed approx. $392K in 2019. NET $149K. Property #5276.

LA HABRA— GP with 22 yrs of goodwill.

Has 4 eq ops. Grossed $974K in 2019. Buyer’s net of$259K. ID 5298.

CORONA DEL MAR—Well established GP

with walking distance to the ocean. Consists of 3 eq ops. Grossed approx. $788K in 2019.

Property ID #5285.

LONG BEACH—Established in 1985. GP in a 2 story prof. bldg. w/ 4 eq ops and 2 plmbd not eq on a 1,800 sq ft suite. Grossed approx. $718K in 2019. Property ID #5302.

FOUNTAIN VALLEY— GP in strip shopping center w/ great street visibility. Grossed $238K in 2018. Has 4 eq ops and 1 plmbd not eq. Great staff. Property ID #5293.

LOS ANGELES—GP with 50 years of goodwill on 32 story condo . ID #5302.

GARDEN GROVE—GP w/ 28 yrs of goodwill.

Has 3 eq ops and 1 plmbd not eq. Grossed $539K in 2019. ID #5323.

RESEDA - GP established in 2005 with 5 eq ops in a one story bldg. Grossed $1M in 2019. Net $314K. ID #5317.

ROWLAND HEIGHTS— Estab. in 2009, this GP is located in a 1 story free standing bldg.

Grossed approx. $806K in 2019. NET $314K. Property ID 5278.

IRVINE— Unique practice specializes in Workers Comp. Established in 1974.

Grossed $1.1M in 2019. Net $352K. ID #5318.

LAGUNA NIGUEL - General Practice with 3 eq ops in single story shopping center.

Grossed approx. $514K in 2019. Property ID 5301.

We hope that you and your family are safe and healthy.

CONTACT US FOR A FREE CONSULTATION Phone: (800) 697-5656

NEWPORT BEACH—Beautiful fee for service GP, located in a corner 2 story med bldg.

Well established practice with 4 eq op with windows views. Grossed approx. $616K in 2019. Property ID #5310.

SOLD

SANTA ANA— General practice with 40 years of goodwill in single story busy shopping center. Has 3 eq ops and 1 plmbd not eq. Grossed approximately $180K in 2019.

Property ID #5161.

San Diego County CORONADO— GP established in 1986 with 4 eq ops in a 2 story building. PPO & Cash only. Grossed $990K in 2019. Buyer’s net $345K. ID #5265.

EL CAJON (GP) - Price Reduced! Consists of 5 eq ops and equipped with 3D Sirona CBCT Digital X-ray. Grossed over $1M in the past 10 years. Property ID # 5265.

EL CAJON—General practice with 30 years of goodwill in a 2 story medical building.

Has 4 eq ops and 1 plmbd not eq. Grossed $537K in 2019. Net $204K. Property ID 5321.

Inland Empire LA QUINTA— Price Reduced! Well established GP with over 8 years of goodwill. has 8 eq ops. On a the busiest major intersection. Grossed approx. $1.5M for 2019.

NET $344K. Property ID #5130.

SAN BERNARDINO - GP established circa 1950 located in 2 story bldg. Has 4 eq ops in approx. 1,500 sq ft suite. Grossed approx. $322K in 2019. Seller is retiring . Property ID #5292.

UPLAND—Beautiful general practice located in 2 story building with 4 equipped operatories. Grossed approx. $920K in 2019.

youtube.com/mycpsteam

faceboook.com/mycpsteam

WWW.CALPRACTICESALES.COM CA BRE #00283209

RM Matters

C D A J O U R N A L , V O L 4 8 , Nº 8

Returning To Work: A Compassionate Approach to Staff Well-Being TDIC Risk Management Staff

P

ractice owners wear many hats.

Not only must they be experts in clinical care but also in countless aspects of regulatory compliance, marketing, operations and employment practices. And one of their most essential hats to wear is team leader. From the hygienist to the receptionist, employees often look to practice owners for leadership and to help them navigate emotional, social and financial challenges in the workplace.

Today, staff need strong direction and guidance more than ever before.

The COVID-19 pandemic has instilled feelings of stress, anxiety and fear in many dental professionals. Staff may be returning to work with significant anxiety over their own health and safety, not to mention financial worries, child care concerns and general unease about the current environment.

The Dentists Insurance Company has reported an increase in calls to its Risk Management Advice Line from dentists seeking guidance on how to address employee stress. Some dental practice staff are expressing concerns and hesitation about returning to work for fear of contracting COVID-19. Some are concerned because they live with a medically compromised or elderly family member. Still others are unable to report to work because of a lack of child care.

As team leaders, practice owners are being called upon to provide their staff with support in their time of need. While distraction, stress and fear are normal and expected during this time, a compassionate approach can give your staff the sense of well-being they need to return to the workplace with more confidence.

These are unprecedented times and employees need reassurance, so it’s important to provide a sympathetic ear no matter what the issue or fear may be.

To address these fears, dentists are advised to approach their staff with care, compassion and understanding.

Having open conversations and truly listening to the concerns expressed can go a long way in calming nerves on both sides. These are unprecedented times and employees need reassurance, so it’s important to provide a sympathetic ear no matter what the issue or fear may be. Some

answers

From one-on-one risk management advice by phone to informed consent forms to expert-led seminars, we’re here to help you practice with confidence.

We are The Dentists Insurance Company.

Learn more at tdicinsurance.com/rm

Protecting dentists. It’s all we do.

®

800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783

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RM MAT TERS C D A J O U R N A L , V O L 4 8 , Nº 8

practices have even implemented a system for submitting anonymous comments or questions so employees can feel empowered to speak up.

Use a Facts-Based Approach

With so much misinformation circulating, separating fact from fiction can be difficult. As the team leader, it is up to you to educate your employees and reassure them that you are committed to providing a safe working environment. If you haven’t already, consider holding a training focusing exclusively on COVID-19 best

practices with ample time to answer questions and address specific concerns.

Additional training in infection control, treatment-area disinfection and donning/ doffing personal protective equipment (PPE) may also help put staff at ease.

Spend time studying guidance from the Centers for Disease Control and Prevention (CDC), OSHA and other state and federal agencies to familiarize yourself with the latest guidelines and provide updates regularly. These guidelines have been fluid in response to the ever-changing pandemic environment. Keeping

employees informed and involved on the current protocols can help alleviate feelings of helplessness. It also demonstrates that you take the safety of your staff seriously and are adding informed steps to minimize risk.

CDA members also have access to a back-to-practice staff training program, which can help you and your team navigate best practices and protocols for mitigating COVID-19 in the workplace. The training covers patient and staff infection control and patient scheduling, including a patient appointment dress rehearsal.

Provide Flexibility

If job responsibilities allow, consider providing employees with a bit of flexibility in their schedule.

Some duties can be performed remotely, allowing staff to stay home if needed. Others may be struggling to balance work life and home life, so allowing them to come in later or leave earlier may help ease their frustration.

Some practices have implemented alternative workweeks and staggered shifts to reduce the number of employees in the office at one time.

High-Risk Employees

In some situations, employees have been hesitant to return to work because either they or someone in their household is at high risk of contracting the virus. While this caution is certainly understandable, employers must do all they can to reassure them that all recommended safety precautions are in place.

Some employees are considered high risk because of conditions protected under the federal Americans with Disabilities Act and the Fair Housing and Employment Act. For example, diabetes is a protected group 406 AUGUST

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C D A J O U R N A L , V O L 4 8 , Nº 8

under both acts, meaning employers are required to make reasonable accommodations for diabetic workers, such as moving workspaces 6 feet apart and installing Plexiglas barriers.

Although accommodations are expected, and in some cases required, making assumptive health and safety decisions on behalf of your employees is ill advised. For example, limiting assigned work hours without employees’ approval because of their age or medical status can be grounds for a discrimination claim. Instead, provide the employee with reassurance, but ultimately allow them to make the decision.

Lack of Child Care

Many parents are struggling to return to work due to a lack of child care. Some child care centers remain closed, and those that have reopened have reduced capacity.

Due to lost wages during shelter-inplace orders or practice interruption, some parents may simply not have the means to pay for child care.

Practice owners are advised to have open conversations with employees to discuss the possibility of flexible hours or telework, if possible.

Employers should also be prepared to provide resources to parents, such as links to state and local agencies that can provide assistance. You can access state-by-state COVID19-related child care resources via the federal Office of Child Care.

Employee Protections

Peter Finn, an attorney with Bradley, Curley, Barrabee & Kowalski PC in Larkspur, Calif., notes that there are typically no legal protections for employees of dental offices or health care facilities

who refuse to return to work due to COVID-19-related reasons. Although Congress passed the Families First Coronavirus Response Act to provide additional leave to those impacted by the pandemic, the act does not typically apply to employees of health care facilities — including dental practices. The act provides the ability for businesses with fewer than 50 employees, under certain circumstances, to self-exclude from the extended leave for child care purposes when an extended leave would jeopardize the viability of the business. Employers have the ability to seek 100% reimbursement for wages paid under this act through IRS tax deductions. However, some protections exist with regard to OSHA, Finn said. If an employee raises concerns that the office is not following proper health and safety protocols by providing PPE or implementing social distancing guidelines, the employee may be protected.

“In addition, federal OSHA law permits an employee to refuse work if the employee believes in good faith that doing the work would place them in ‘imminent danger’ and the employer has failed to eliminate the danger,” Finn said.

Even when employees may not have specific protections under law, it is recommended that the practice owner attempt to work with the employee to find a solution that meets the needs of both parties.

Keeping staff safe is of the utmost importance, and taking a collaborative, compassionate approach goes a long way in reassuring staff and keeping morale high. Should an employee still refuse to report to work, consult with an attorney prior to considering terminating their employment.

Care and Compassion

Although dental practices are cautiously resuming care, fears over health and safety and financial security remain. As leaders of the dental team, practice owners are encouraged to take a gentle, flexible and compassionate approach when addressing employee concerns during this time. A dental team is a close-knit group, one that’s often considered family, and a little empathy can go a long way in assuaging fears and getting back to business. n TDIC’s Risk Management Advice Line is a benefit of CDA membership.

If you need to schedule a no-cost consultation with an experienced Risk Management analyst, visit tdicinsurance. com/RMconsult or call 800.733.0633.

AUGUST 2 0 2 0 407

Specialists in the Sale and Appraisal of Dental Practices

Serving California Dentists since 1966 How much is your practice worth??

Practices Wanted

The Sun will Shine again but Brighter!

NORTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 Raymond and Edna Irving Ray@PPSsellsDDS.com www.PPSsellsDDS.com

SOUTHERN CALIFORNIA

(714) 832-0230 – (800) 695-2732 Thomas Fitterer and Dean George PPSincnet@aol.com www.PPSDental.com

California DRE License 1422122

California DRE License 324962

6181 CARMEL VALLEY VILLAGE - START-UP Slam dunk for nominal investment. 48-year history providing dental care at same location. Great curb appeal. Fully equipped & furnished 4-ops. $1+ Million/year location. Only practice in Village. Next practice 10-minutes away; then 17-minutes to practices in Carmel. Landlord is daughter of original dentist who worked as hygienist for her Dad & later her Husband; and transitioned to Manager.

Shut-down April. Purchase equipment & furnishings, enter into Lease and open doors. Patients return. Operate out-of-network Great 2nd office for Monterey / Salinas Area dentist or starter for go-getter.

6180 SAN FRANCISCO CONCIERGE PRACTICE Averages 3-to-5 Dentist patients day. Available Profits totaled $391,500 in 2019 with 9-weeks off. Located in service & shopping area of high income zip code with average household income of $286,800. Décor, delivery systems, technology reflect $258,000 in upgrades. Fees will not change. Collected $796,500 in 2019. Full Price $550,000.

6179 CENTRAL MARIN COUNTY Extremely strong foundation as evidenced by 7-days of hygiene. Beautiful office and great location.

Collections last 3-years have averaged $870,000. Owner is conservative with patients well educated on issues occurring in their mouths.

6178 DESIRABLE CONTRA COSTA COUNTY COMMUNITY Located in tony community where median household income is $157,450. Collections in 2019 totaled $780,000 reflecting nice growth from 2018’s totals of $655,000. And Owner just raised UCR Fees by 11.4%. Patient rich. 5-days of hygiene. Paperless and digital. Beautiful office with lots of nice upgrades.

6177 SALINAS During Great Recession, Salinas dentists did well as Salinas Valley is one of California’s most productive agricultural regions and is the engine driving this area’s economy. As such, Salinas shall bounce back quickly from Covid Hangover. Under-performing practice collected $935,000 in 2019. 5-days of Hygiene. Housed in beautiful 6-op suite. Condo optional purchase. Great platform to bring in specialists.

6176 SANTA CRUZ Delta PPO practice seeks Successor skilled in placing implants. Last 2-years averaged $1,180,000 in collections and $735,000 in Available Profits. $480,000 invested in technology to make this possible.

4-days of Hygiene. Full Price $675,000.

6174 HUMBOLDT COUNTY’S UNIVERSITY COMMUNITY – ARCATA Best location, great foundation. Owner works 3-day week by choice. 2019 collected $360,000. Practice wants to be full time. Full Price $50,000.

6172 WALNUT CREEK – OUT-OF-NETWORK 2019 collected $850,000 with Profits of $430,000. 4-days of Hygiene. Requires skilled, easy temperament and great communicator as Successor. Seller shall work-back to assist in transition.

6171 SANTA ROSA Great DNA in long-established practice. Strong patient foundation per 6+ day Hygiene Schedule. 2019 collected $990,000 with Available Profits of $338,000. Great Team. Full Price $213,750.

6170 MANTECA / RIPON AREA 2019’s revenues totaled $860,000 with Available Profits of $352,000. 5-days of Hygiene. Refers endo, most OS and implant placements. Extensive patient base. Successor should contract with specialists to perform referred work. Facility perfect for making this a fullservice practice. Full price $450,000.

6165 ROSEVILLE ORTHO – OUT-OF-NETWORK Stanford Ranch. $455,000 invested in build-out, furnishings, computers and equipment. 3-chair Bay. Digital Pan with Ceph. Averages 3 New Patients per month. Full Price $125,000.

6164 SAN FRANCISCO’S UNION STREET – OUT-OF-NETWORK Highly regarded as evidenced by 9-days of Hygiene per week. Collections topped $2 Million each last 3-years with Profits averaging $1 Million.

Paperless. 3D Cone Beam.

Great Time to Think about Change. Not doing the Type of Dentistry You would like to do? Look to Tom Fitterer & PPS to plan your future.

D

SOL

BAKERSFIELD AREA Small city. Seller built 4,500 sq.ft. beautiful home for $450,000. (Cost $1.5 million in OC.) Hi identity dental building. 7 Adec ops. 3,000 sq.ft. next to Health Center for 1.2 million people. Established 32 years. Grossing $1 Million. Buy all at Bank Appraisal, 5 Dentists serving 40,000 market area patients.

BEAUMONT AREA 8,000 new homes to be built 5 minutes away. Retiring DDS established 1988. 1,550 sq.ft. 3-ops. Rent $1,650. Average Gross $365,000.

BEAUMONT / BANNING Senior DDS Grossing $250,000. 1-op. Rent $960 per month. Take home $200,000.

EAST LOS ANGELES 60 years old. 3-ops. Rent $1,600. Part-time Senior Grossing $285,000 on 2-days. Do $500,000 on 3.5 days. Hi visibility. Bargain at $195,000.

HEMET - HISPANIC AREA Includes Dental Building. Established 50-years.

Absentee Seller. This is a neglected practice. Beautiful 5-op office. Open part-time.

Will do $500,000 first year. $1 Million in 3-years like one prior owner. Pay Mortgage that never goes up. Part-time Seller will transition. Cerec. $250,000 buys practice.

Small down buys building. Historic location. Live in apt if you like during week, live on beach on weekends.

GP INNOVATOR Gross $1,700,000. Net over $1 Million. Nothing fancy, low tech dentistry. Full Price $1,500,000.

INLAND EMPIRE - UNION PRACTICE Gross $550,000 2.5 days by choice. Net $350,000. 5-ops.

INTERSECTION OF 210 / 57 Hi identity. 25-years old. Unbelievable state-of-art.

10-ops, new everything. Recent $500,000 renovation. Cone beam, Cerec, lasers.

Grossing $1,100,000. Seller has 2-practices, cannot do both justice. This is a $2,000,000 location.

LA HABRA - HUGE SHOPPING CENTER Well maintained. PT Seller will stay.

6 ops.

LAGUNA WOODS Grossing $800,000 part-time. Should gross $1,000,000.

MARINA DEL REY Take home $1 Million Net. HMO checks $5-to-8,000/month.

Resume required ORANGE COUNTY Established 1970. Near Chapman / Tustin intersection.

Grossing $400,000. Merge or Grow PALM DESERT Hi identity. Established 2007. Terrific one girl staff. Mostly Hispanic. Low overhead. Rent $1,600. Gross near $300,000. Semi-retire on 2-or-3 days. 4-ops, 2-equipped.

PALM SPRINGS AREA $1,500,000 includes specialists. Grow to $2,000,000+.

8-ops. Best buy.

TORRANCE – PACFIC COAST HIGHWAY Market to Palos Verdes to LAX area. 50-to-70,000 autos pass daily. Across street from major retailers with Hi Identity.

High Tech Adec like-new, 6-ops, no expense spared. $5,000 HMO checks pays 56% of cost to buy. Within 36-months, Buyer will net $50,000 a month. After 5-years, Net of $1,000,000 per year is achievable goal.

REDONDO BEACH Semi-retire. Work 2-to-3 days, low overhead. Established 20years. 2-ops. Super staff. Rent $1,550. Seller refers a lot. Full Price $118,000.

SAN DIEGO GROUP 4-office DSO grossing $3.7 Million.

SOUTH BAY OPPORTUNITY For talented GP to Net $50,000/month.

TEMECULA SHOPPING CENTER High visibility. 5-ops. Grossing $40-to-50,000 month. Absentee owned. Hands on owner will double first year.

Bargain.

THOUSAND OAKS Classic practice. Established 42-years. One Partner willing to work back 3-to-5 years. Grossing $1 Million. Refers lots to Specialists. 5-ops. Owners own 25% of Building housing 4 Dentists including Ortho. Great for Specialist or GP. UPLAND Established 38-years. 3-ops. Grossing $330,000. 2000 active patients

Regulatory Compliance

C D A J O U R N A L , V O L 4 8 , Nº 8

COVID-19 and Respiratory Protection CDA Practice Support

T

he onset of new regulatory requirements for dentistry earlier this year was brought about by the SARS-CoV-2 virus and the CDC and Cal/ OSHA recommendations for dental health care workers to wear respirators for their protection. When an employer makes the decision to use respirators in their office, the employer must comply with regulations that help ensure the safe and effective use of the respirators.

The Cal/OSHA respiratory protection regulation1 applies to the use of respirators at California workplaces.

The most used respirator in the U.S. health care industry is the N95 model.

Technically known as “disposable filtering facepiece respirators,” surgical N95s are typically inexpensive and disposed of after single use. They are normally approved by both the National Institute of Occupational Safety and Health (NIOSH) and the U.S. Food and Drug Administration (FDA). The COVID-19 pandemic created great demand for the N95, which led to worldwide shortages. In response to the demand, the FDA issued a series of emergency-use authorizations2 permitting health care providers the use of: ■ Non-FDA approved, NIOSHapproved particulate filtering respirators. These include nonsurgical N95s, N99, N100, R95, P95, P99, P100 and reusable half- or full-facepiece elastomeric respirators. The elastomeric respirators are reusable because they can be disinfected.

■ Imported non-NIOSH approved particulate filtering respirators. Most of these respirators are manufactured by 3M in several countries and have different respirator model numbers.

■ Non-NIOSH approved

particulate filtering respirators manufactured in China. There are several different model numbers, including the KN95.

Health care providers may also use powered air purifying respirators, also known as PAPRs. This type of respirator is typically worn by someone who is unable to wear a tight-fitting respirator as determined by a fit test.

To assure a tight-fitting respirator provides the wearer with necessary protection, it should be fit tested.

Employers are required to provide the initial and annual fit tests and training on the use, maintenance and care of the respirator. The annual fit-test requirement is suspended for the duration of the pandemic. The regulation also requires that an employer prepare a written respiratory protection program that designates a program administrator and describes: ■ Respiratory hazards.

■ Type and characteristics of respirators available for use by employees.

■ Medical evaluation — what is involved; information provided to the evaluator; when additional medical evaluation is necessary.

■ Fit-testing process and when it needs to be redone.

■ Respirator use.

■ Maintenance and care of respirators.

■ Training and information — why respirators are necessary; limitations of their use; how to inspect, put on, perform seal check and remove; recognition of medical signs and symptoms that limit an employee’s effective use of a respirator.

■ Program evaluation – includes evaluation of respirator alternatives in the workplace and employee involvement.

If the dental office protocol does not include staff respirator use but an employee chooses to wear one, a medical evaluation and fit test are not required as long as the employer has determined that the employee’s use of the respirator will not create a hazard. The employer must provide the employee with basic information on respirator use and maintenance.

A properly fit-tested respirator will provide the best protection to an individual who is at high risk of exposure to the SARS-CoV-2 virus. n REFERENCES 1. Title 8 CCR Section 5144. www.dir.ca.gov/ Title8/5144.html.

2. U.S. Food and Drug Administration. Emergency Use Authorizations.www.fda.gov/medical-devices/emergencysituations-medical-devices/emergency-use-authorizations.

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.

AUGUST 2 0 2 0 409

CARROLL &COMPANY 4408 SONOMA COUNTY Beautiful 2,100 sq. ft., 6 op practice, 4 doctordays & 3 hygiene days per week. Average gross receipts $1M+.

Asking $590K. 23-year perio practice, also ideal for GP; loyal, seasoned staff and great location.

4407 SAN MATEO GP Exceptional 5-operatory San Mateo practice in popular health provider neighborhood generating significant daily business draw. Beautiful 2,200 sq. ft. seller-owned facility, handsomely equipped to highest standards. Average GR $1.4M, average overhead 61%. Seasoned and loyal staff. Seller willing to help for a smooth transition.

4381 SOUTH SF GP 23 year practice close to Kaiser Hospital; phenomenal shopping and residential mix LDarea. 4 op facility with new/ SO gross receipts approximately recently upgraded equipment. Average $250K with average 60% overhead. Asking $170K. 4414 MORGAN HIL GP & BLDG Love where you practice! Pristine, stunning, well appointed office with modern equipment and digital x-ray.

LD Doctor deliver system can be setupOfor S right or left-handed dentist. 1,700+ active patients. 2019 GR $1.1M with adj. net of $508K. 3.5 doctor days/ week & 6 hygiene days/week..

4394 SANTA CRUZ GP Retiring seller offering 33+ years of goodwill in stunning 1,534 sq. ft. facility with 4 fully-equipped ops. Pristine leasehold improvements/gorgeous cabinetry make this a must-see! Prime corner location with dedicated parking lot, situated in one of the most desirable areas of Santa Cruz, close to shoreline and tourist attractions. 2019 GR $887K with adj. net of $353K. 1,500+ active patients with average of 19 new patients/month. Seller works 3+ days/week with 5+ days of hygiene.

Asking $729K. 4405 LOS GATOS GP 30 year practice in beautiful modern, office and LD desireable location with two 5 year SO options to extend lease. $1.2M average gross receipts with 56% average overhead. Asking $986K. 4382 MONTEREY COUNTY GP Established practice in Monterey County, California Coast. Multiple ops can expand, approx. 900 active patients, 4 days of hygiene per week. Ideal for a mature, experienced dentist for this adult-focused practice in an Extraordinary location. Periodontal emphasis with communicative technology in each operatory for multiple crown and implant restorative procedures. Loyal, committed staff will remain through transition. Future opportunity to purchase office building.

4351 SEBASTOPOL AREA GP & BLDG. Beautiful, modern practice in seller-owned building (available for purchase); 3 fully-equipped ops, room for a 4th. Pristine equipment including digital X-ray, most purchased 2016-2018. 2019 GR annualized at $679K+ with adj. net of $210K. Average 3.5 doctor days/week and 4 hygiene days/week. 800 active patients, all fee-for-service. 70+ years of goodwill = long-standing, loyal patient base in scenic vineyard country. Asking $305K for practice, $425K for building. Owner/doctor willing to help for smooth transition.

4399 SAN JOSE GP Well established, San Jose neighborhood practice offering 40 years of goodwill. Gorgeous office in pristine condition located on a well-traveled thoroughfare with incredible views of the eastern foothills. 6 fully equipped ops in beautifully appointed 1,860 sq. ft. office.

Seasoned and loyal staff. Approx. 2,000 active patients with 12-13 new patients per month. Approx. 8 hygiene days/week. Average GR $1.3M+ with adjusted net of $533K. Seller will help for smooth transition. Asking $977K.

carroll.company

dental@carrollandco.info

“Matching the Right Dentist to the Right Practice�

4415 WATSONVILLE GP & BLDG Offering 35 yrs of goodwill in the growing coastal community of Watsonville, also serving the Aptos and Santa Cruz areas. Charming and renovated 4 op office in 1,320 sq. ft. Approx. 450 active patients with an average of 10 new patients/mo. Incredible upside potential with excellent management systems in place. Endo, Oral Surgery and all Ortho procedures referred out. Last 2 yrs average Gross Receipts $275K with average adj net of $159K on just 1.5 doctor days/week. This is a real opportunity for growth. Bldg condo is also available for purchase. Asking price $175K for practice and $300K for condo.

4360 SALINAS GP Seller transitioning into retirement and offering wellestablished practice located near downtown Salinas and Salinas Valley Memorial Hospital. Average Gross Receipts $250K. Asking $133K. 4416 SF FACILITY Located on Lyon street, closest major cross street Lombard. 1,600 sq. ft. turn-key dental facility. This street level space has over $350,000 of improvements completed for professional use and ready to go as a dental office. Asking $35K. 4392 SAN JOSE GP Offering 40+ years of goodwill. Excellent location in beautiful bldg on well-traveled thoroughfare. 6+ ops in 1,882 sq. ft. Lots of natural light with views of the eastern foothills. 1,800 active patients. 8 hygiene days/wk. Average GR $900K with adj. net of $295K. Terrific upside potential. Asking $621K. Owners will help for smooth transition.

4387 SF GP 50 year Nob HIll neighborhood practice with approximately 1,000 active patients. Almost no Delta Premier patients. Average GR $600K. Seller transitioning into retirement. Asking $315K. 4362 MARIN COUNTY GP 36 years of goodwill, Seller-owned 1,550 square foot facility with 5 fully-equipped ops. Prime position in charming town; desirable area known for temperate weather, easy, outdoor living and natural beauty. No Delta Premier patients. Excellent reputation and word-of-mouth referrals. Retiring seller will help for smooth transition. Average Gross Receipts last 2 yrs is $450K. Asking $248K for the practice. Bldg condo is available for purchase.

4389 SALINAS GP Stable, 2400+ patient base. Seasoned and dedicated staff. Practice with an emphasis on Restorative treatment. 4 doctor days & 5 hygiene days per week. Average GR $910K. Asking $670k. Retiring owner.

4375 LOS GATOS DENTAL FACILITY Unique opportunity in highly desirable area! Seller offering two full suites of state-of-the-art equipment and modern, 2-operatory facility including furniture, fixtures and leasehold assets in medical office building adjacent to Los Gatos Community Hospital. Asking $250K. UPCOMING: Redwood Shores GP $1.2M+ avg. GR, Palo Alto GP $1.4M+ avg. GR, Redwood City GP $1M+ avg. GR

Mike Carroll

Pamela Carroll-Gardiner

(650) 362-7004

Mary McEvoy Carroll

CalRE# - 00777682

(650) 362-7007

Ethics

C D A J O U R N A L , V O L 4 8 , Nº 8

Is It Ethical To Ask for Reviews?

Paul Hsiao, DDS, MPH, JD

S

taff get reviews. Online software and apps ask for reviews. Companies give discounts for reviews.

Ultimately, what is ethical and how should these reviews be garnered without unbiased influences?

It’s interesting that a dental office in one community may have hundreds to thousands of reviews and a similar office nearby has one or zero reviews.

How is this possible? Either someone is doing everything right or another person is doing everything wrong.

As society becomes more and more review-based, it becomes harder to stand out from the crowd if you do not have a certain amount of online presence. Online presence could include your website, reviews on different platforms, videos of you, your Facebook or LinkedIn pages and whatever else the web has collected over time. When would it be appropriate to ask a patient for an online review? Do we ask patients to write the review when they’re in the waiting room, when they’re waiting for treatment during downtime in the chair or after their dental procedure?

If you did something amazing and the patient voluntarily writes a review, just say thank you. When you do something awesome, ask for an awesome review. Your patients who love you and your staff will always be the foundation of your practice, so why not leverage your relationship and great experiences? Patients may be too shy to tell the world you’re amazing, preferring to keep you for themselves.

But loyal patients will want you to succeed and might just make the effort if you bring it up. The CDA Code of Ethics says that advertising

should not be false or misleading (6A).

Because online reviews are a form of advertising, they should be honest reviews by actual patients. Also, you want to avoid giving anything of value in exchange for the review, such as a gift card or free service, because doing so without conspicuous disclosure can be considered false and deceptive advertising by the Federal Trade Commission.

Remember this saying: “If you ask, you shall receive; however, be careful what you wish for.” If you do get a negative review, don’t panic.

A small number of negative reviews are expected for most businesses and provide credibility to the positive reviews. It is recommended that you contact the patient offline, separate from the review platform, to avoid a violation of HIPAA. For more information, see the Practice Support resource at cda.org/onlinereview-generation-best-practices.

In this world of instant gratification, I would suggest asking for a positive review; as solo practitioners or even small group practices, many of us benefit greatly from reviews. Not everyone can afford automated platforms to generate reviews, so why not use our words and politely ask patients to say something nice about their experiences? Plus, with so many years of good will, patients would gladly spend a few minutes writing about their dentist’s awesomeness.

The purpose of the CDA Code of Ethics is to guide members in service to the public to uphold ethical conduct between dental providers and ethical promotion of dental practices and services. Being

a dentist is a privilege, and we have a responsibility to society and to fellow dentists to conduct activities in an ethical manner. Therefore, if we are good at what we do, why not ask our patients to directly review us rather than use computer software to generate their responses. n Paul Hsiao, DDS, MPH, JD, is a general dentist practicing in Fresno, Calif.

He is a fellow of the American College of Dentists and the International College of Dentists. Dr. Hsiao served on the CDA Judicial Council.

AUGUST 2 0 2 0 411

Tech Trends

C D A J O U R N A L , V O L 4 8 , Nº 8

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

Reps & Sets (Free or 99 cents per month, Repsio Ltd.) Reps & Sets contains a comprehensive library containing hundreds of exercises that will satisfy most users. From cardiovascular to repetition-based, each exercise is illustrated with helpful instructions and detailed muscle diagrams. Users can create custom workout programs by choosing any number, combination and order of exercises or select from a list of premade programs sorted by type, difficulty, duration and equipment. Once a workout has started, users simply perform each exercise in the program and check off the items in a to-do list manner. For time-based exercises and rest periods, the app contains a timer that alerts the user at the end of the time period. Workout progress, rest period timers and notifications are also available through a lock-screen widget or the companion Apple Watch app. Workouts can either be completed through the iPhone app or Apple Watch app, with the latter recording important heart rate information. All workout and profile data can be shared with Apple Health or exported as a CSV file directly from the app. Users can upgrade to a premium subscription, which provides new monthly illustrations and workouts and unlocks the ability to customize and check off exercises directly from the Apple Watch app. Without the subscription upgrade, users interact only with the iPhone app to complete workout exercises while the Apple Watch app has minimal functionality. As a result, many users will find that the default auto-lock timer in their iOS settings is set to a duration less than a time-based exercise, which will lock the iPhone screen mid-exercise and force users to unlock their devices to continue interacting with the app. There are easy workarounds to these minor interface inconveniences, but the Apple Watch app with a premium subscription is clearly the ideal solution.

With Reps & Sets, people can take charge of and track their own health and fitness while staying at home during the pandemic.

While there are advantages to pairing the Apple Watch app to a paid subscription upgrade, there is no replacement for the personal desire and motivation needed to maintain a healthy lifestyle during this new normal.

— Hubert Chan, DDS

Microsoft Power Apps ($40 per user, per month, Microsoft)

Meeting the needs of employees, patients and peers has never been more difficult as every obstacle seems to require a flexible, custom solution. The new normal — masks for all, social distancing, contact tracing — is here to stay for the foreseeable future. Dental practices are adjusting, but they are encountering new recommendations, rules and regulations at every turn. While not the silver bullet to solve all of dentistry’s COVID-19 related hurdles, Microsoft Power Apps has the potential to help tech-savvy practitioners augment their electronic record-keeping, personnel management tools and intraoffice communication protocols.

Power Apps is billed as a platform to democratize “the custom business app building experience by enabling users to build featurerich, custom business apps without writing code.” On the surface, Power Apps appears to deliver. Purchase Power Apps online, sign into the Microsoft Office 365 account and either make something from scratch or choose from a host of templates that appear most applicable like “onboarding tasks,” “budget tracker” and “customer lookup.” Unfortunately, every subsequent act in Power Apps grows exponentially more complex. Users without programming experience will struggle as almost any customization results in suddenly interacting with an unintentional group of functionalities. For example, implementing a submission review and confirmation page is not a simple click, but rather an involved process that requires formulas to check required fields, an explicit statement that prevents incomplete data from being submitted and an additional screen of text. Not insurmountable, but not intuitive to the average user.

Reducing mobile app creation to a few clicks misses the reason why a custom application is required: There’s a problem that has not been optimally answered by the solutions closely available. While houses have been built with nothing more than a hammer and handsaw, this strategy is not advisable when there are other more effective tools with trained individuals ready to use them. Users with a programming background will find Power Apps limited in capability; users without an interest in technology will be overwhelmed. Power Apps is an excellent gadget for the population of tech-savvy practitioners not interested in learning to code. Ultimately, it is a simple tool built to address complex problems and it shows.

— Alexander Lee, DMD

412 AUGUST

2020

®

Brilliant Education CDA Presents goes digital.

Join in our exciting virtual convention this September and take part in required courses, a full clinical education program and fun new ways to connect. Watch for more details about our schedule of courses for the entire dental team, roster of leading speakers and interactive exhibit hall — all online.

C.E. is online right now.

CDA offers a variety of webinars, web-based courses and audio learning options. Learn more and register to earn convenient C.E. at cda.org/brightbox.

SAVE THE DATE VIRTUAL CONVENTION September 10–12, 2020

Anaheim, California May 13–15, 2021 May 12–14, 2022

San Francisco, California September 9–11, 2021 September 8–10, 2022

Like us @cdadentists

Connect with us California Dental Association

Follow us @cdadentists

Follow us @cdadentists

150 YEARS STRONG

CDA. WE’VE BUILT THIS TOGETHER. In 1870, the California Dental Association was founded by 23 visionary dentists.

In 2020, we’ve grown into a diverse, inclusive community of 27,000 members.

Today, we continue to face new challenges with passion and purpose.

Working together, we’re building an enduring future.

Explore our heritage at cda.org/150.

1870 2020