A Conversation with Dr. Dushanka Kleinman
This month, the former Chief Dental Officer of the US Public Health Service discusses what she has learned in her professional experience, the state of dental research, and what challenges face the profession down the road.
Inside Dentistry's James B. Bramson, DDS, president of Bramson & Company, and Dushanka Kleinman, DDS, MScD, the former Chief Dental Officer of the US Public Health Service, discuss dental research and how far the profession has come since Oral Health in America was published in 2000.
INSIDE DENTISTRY (ID): What is in store for dentistry in the years to come?
DUSHANKA KLEINMAN (DK): This is a great question. The simple answer is “it depends.” It depends upon how the profession responds to the many challenges and opportunities facing it at the moment. Some of the challenges have been with us for decades, while others are relatively new. The questions before us are numerous: How can we improve oral health literacy? What specifically can be done to achieve health equity and eliminate health disparities? How can we ensure a sufficient workforce? What is needed to implement the dental components of the healthcare law and the relevant parts of the HITECH Act? What else can increase the numbers and capacity of dental faculty, and improve support for dental research? How can we incorporate research findings more rapidly and more effectively? How can we rebuild our dental public health infrastructure? The list goes on and on.
We are seeing interest and proactive action from the public and policy makers to improve oral health literacy and to provide accessible and appropriate dental care. Dentistry has the opportunity to take a leadership role and address these needs effectively and efficiently. However, we need to build trust and take collaborative action within and beyond the profession to meet the oral health needs of the public. We need a strong, united voice to ensure fiscal resources are available to take these actions. With oral health promotion as our common goal, the future of dentistry is unlimited.
ID: What needs to be done to rebuild our dental public health infrastructure?
DK: In terms of the public health infrastructure, the needs are extensive but straightforward – money, people and strategic approaches. We need positions of leadership for dental expertise and oversight funded and filled at federal, state and local levels . In the federal sector, it is critical to have dental expertise in agencies throughout DHHS and other departments. For example we currently do not have any dental expertise in the Agency for Healthcare Research and Quality or Centers for Medicare & Medicaid Services. We need senior level appointed dental directors in every state. We need a cadre of trained staff for these positions and programs. We must rebuild and expand the development of a dental public health oriented and trained workforce to fill these positions. Along with these positions we need operatingresources to plan, implement and evaluate effective disease prevention and oral health promotion programs; monitor oral health status; and integrate oral health into the care, education and research programs. With this infrastructure we could maximize the opportunities to integrate oral health into primary care, we could take full advantage of the opportunities brought to us with the Patient Protection Affordable Care Act, and we could work more effectively to extend care to adults. .
ID: What attracted you to dentistry in the first place?
DK: I was originally attracted to dentistry because of its role in the healing professions. As an “outsider” choosing a career direction, I viewed dentistry as a profession that provided specialized and “appreciated” healthcare in a controlled and efficient environment. Candidly, I also viewed the profession as ideal for a woman who plans to have a family and to work. I must admit, my only prior exposure to dentistry was as a patient. Once I entered the profession, though, I realized the depth of the opportunities it offered.
ID: Were you interested in any other careers before you decided on dentistry?
DK: I majored in zoology and was interested primarily in the science fields. However, at that time in the 1960s, the options were not as diverse as they are now for people in graduate school. So dentistry was seen as an appropriate profession beyond college that would fit with my interests, background, and my perception of what life would be like in the coming decade.
ID: Did you ever face a particularly tough or adverse situation that you really learned a lesson from? Can you tell us about the key challenge or turning point for you?
DK: There are many situations I have faced that have provided me with lessons. One of those includes the events related to the Alaska Dental Health Aide Therapist Initiative. I was involved in my role as the Chief Dental Officer of the US Public Health Service (USPHS), and worked as a team member with senior leadership at the Indian Health Service (IHS) in describing the program, its basis, and need. The key challenge, as I viewed it, was the inability to calmly and comprehensively review and discuss the many public health, legal, and social factors that contributed to the development of this part of the overall Dental Health Aide program. As a result, there were many misconceptions about the program, and inaccuracies in communicating the program to the full range of stakeholders.
The basic lessons include the need to be respectful of the legal rights of communities and community-based initiatives, to be fully and accurately informed, and to collaboratively offer support, options, and services.
ID: In your former positions at the NIH, NIDCR, and as Chief Dental Officer of the US Public Health Service, you were able to influence dentistry, and the health of all Americans. Tell us about your experiences when you were at these agencies.
DK: In all of these positions, I was impressed with the extreme dedication of the individuals and groups I worked with, as well as their commitment to the overall mission of improving and promoting health, including oral health. At the same time, the focus on cancer, mental health, HIV/AIDS, and other conditions easily took priority. It takes continual vigilance and perseverance to ensure that oral health is represented at the table, no matter where you sit.
As an officer in the USPHS Commissioned Corps, I particularly enjoyed the opportunity to work on teams that crossed disciplines, agencies, and departments. A multidisciplinary focus allows for healthy debates, engenders new perspectives, and has the potential to make a greater impact.
It was so important to have a national vantage point, and the ability to work across sectors (education, defense, agriculture, etc) to accomplish our goals.
ID: With that ability to work across and within agencies, did you ever become frustrated with government and how long it takes to accomplish anything?
DK: Definitely. The government is an organization of organizations of organizations, with many cultures. You need to know how to work with them, from the appointed leadership to the rank and file. However frustrations at work are not unique to the government setting. You need to learn about the organization in which you live, learn about the timeframe, pace, and process and identify how to strategically work to move projects and concepts forward. Of course you want things to move very quickly in the areas that you’re passionate about. At the same time, it’s probably more important to be persistent.
ID: In other words, it’s like a series of short races rather than one long marathon.
DK: That’s well stated. Using that metaphor, you also have to keep training and working to break your speed record.
ID: Regarding large public health initiatives, what is the state of fluoridation in the United States? Are we making progress, and why or why not?
DK: Given its safety, effectiveness, ease of administration, and low cost, water fluoridation is still recognized as one of the top 10 public health achievements of the past century. There is no question that it has contributed to major improvements in our nation’s oral health.
We continue to make progress, as measured by the percent of the US population accessing public water supplies with optimum levels of fluoride. Data from 2006 show we are at 69.2%, up from 65% in 2000. This percentage has continued to increase each year, but has yet to reach the Healthy People 2010 objective of 75%. This process has never been easy, especially given that many of the remaining communities with public water systems are small in size. National incremental increases require multiple community-based efforts, including education of the public about the benefits of fluoride.
ID: What particular strategies could be used to incentivize some of those communities?
DK: Even in communities that already have water fluoridation, we need a consistent, strong, persistent campaign to identify, promote, and reinforce the importance of this very efficient, widely available, preventive delivery system. We have not been communicating our knowledge of preventive measures—specifically the role of fluoride, whether it’s in dentifrices, mouth rinses, or in the water—to the public and policy makers. I think we have been conflicted about this, because highlighting fluoride may lead to outcomes that we don’t want. At the same time, the public is not receiving these messages as clearly and strongly as they should. With respect to both large communities and the smaller communities (where community water fluoridation is not possible) the strategy remains education, education, education.
ID: Co-authoring the first-ever Oral Health in America, A Report of the US Surgeon General, was significant. What has been the impact of that report?
DK: The impact of the Surgeon General’s report has not been formally evaluated, so my comments are purely speculative and most likely biased. I believe the report’s release at the turn of the millennium was timely, and served an educational purpose for policy makers, the public, and the health professions.
As the first Surgeon General’s report on oral health, the report added another unique voice to the series of reports and events at that time. The report came in the midst of a series of national events, including a Surgeon General workshop and conference focused on the oral health of children, as well as GAO reports, initiatives supported by the National Institutes of Health and the Centers for Disease Control and Prevention, and a partnership between the Health Resources and Services Administration (HRSA) and the CMS.
The report did open the path for a series of town meetings held around the country that led to A National Call to Action to Promote Oral Health, a document that provides five major actions to move the nation toward eliminating oral health disparities, and improving quality of life. A number of foundations and organizations have adopted this short document to help guide their activities.
Probably most important is the current use of the report as a guidepost to assess how far we have come. While we have moved forward on several key issues that were before us 10 years ago, we still have not addressed many of the report’s recommendations. To do so requires additional funding for research; support for the oral health programs at national, state, and local levels; a never-ending commitment to informing legislators and public officials; and the creation of “oral healthy” policies.
ID: Putting your research hat on, what new findings, concepts, or materials look particularly exciting to you?
DK: I am definitely excited to see the continued work of the health disparities research centers, and the expanded research focus on community-based participatory research.
In addition, I am intrigued by the public health opportunities presented by the emerging development of new diagnostic aids and technologies that allow for real-time analyses. The use of saliva to detect risk factors and biomarkers for conditions such as cancer and cardiovascular diseases adds an incremental tool for all healthcare providers. In addition, the technologies that analyze saliva samples—the labs on a chip—will add to the armamentarium of dentists in their offices and expand their role in primary care. This technology will also allow for further development of field-based population studies and healthcare in general. Having access to rapid analyses not only expedites studies, it allows for immediate healthcare decision-making, which is of major importance as we address the health needs of populations in remote rural regions and in developing nations. Health “care” is an ongoing process, and these technologies have the potential to allow us to integrate the patient-driven self-care and assessment aspects of health with those of services and care provided by healthcare providers. In addition, these technologies will contribute to the evolution of personal health records and their interaction with electronic health records.
ID: Can you comment on the state of dental research in the United States, in terms of money, priorities, and interests? And what does this portend for the profession?
DK: Let me start with the money. We need more. Funding for research is critical if we are to support the proposals deemed outstanding upon peer review. We continue to struggle with the budget for dental research, and this year is no different. The NIDCR and its budget continue to grow and receive support, but not at the same level as the overall NIH budget. We now have a continuing resolution as we enter FY2011, but the Senate action appropriated $422.8 million, which is a 2.3% increase from FY2010. Still, it is below the overall NIH increase of 3.2%. As the Friends of the National Institute of Dental and Craniofacial Research (FNIDCR) testimony highlighted, the NIDCR’s percentage of total NIH funding has decreased 13% from 1998 to the present. Given the increases in costs of research, this reflects an even greater loss of fiscal support for dental research.
I view the investments in research training programs, clinical and community-based participatory research, research centers of excellence, and dental practice-based research networks as essential infrastructure for a strong research base for the profession. We also need investments in demonstration research programs that support translation of research findings into practice, and investments in health professions’ education research.
The issue of where dental research is conducted also warrants attention. Increasingly, the research getting funded is not taking place within dental schools. Higher learning institutions, faculties, and students greatly benefit from research and academic pursuits being connected, not only between dental schools, but also among other schools within academic health centers.
ID: In terms of support for research, isn’t that somewhat due to medical inflation being greater than dental inflation?
DK: Yes, but I think they’ve also done some analyses in terms of constant dollars. However, we’re also falling in our rank within the top institutes and centers. So it’s a mixed bag. One could also look at what, if any, oral health projects are being supported by the National Cancer Institute or the National Institute of Child Health and Human Development. There are a few here and there, but not many.
ID: Why does it take so long for good, solid research to be incorporated and become a best practice?
DK: It takes a long time because there is not a single “one size fits all” systematic approach to the diffusion of innovations. It has been estimated that it takes about two decades for new technologies and new knowledge to truly penetrate practice. This timeframe comes as a surprise to most individuals. But, let’s think about the process. Assume that today we have a new understanding or a new technology that is evidence-based, published in a peer-reviewed journal, and highly publicized. While it may have taken years to get to this point, this is just the beginning of the process. There are numerous next steps. There may be additional studies within the scientific community to validate/replicate these initial findings. The health services community may need to estimate the costs, reimbursement mechanisms, training of associated personnel, and facility logistics. There would be a need to review existing protocols of care within the profession. Also important is how new research findings are incorporated into the education of new providers as well as the continuing education (CE) of those in practice. Current investments in translational research are looking into ways to accelerate this “transfer.”
ID: It seems that once a designated thought leader becomes involved, there’s an immediate increase in uptake, usage, or philosophy adoption by other dentists. So, even though that research has been out there for a long time, there needs to be a catalyst.
DK: We need a better strategy to explore and deliver clinically-relevant, science-based information to dentists. Obviously, there are “thought leaders” that practitioners follow. Perhaps we need to nurture these leaders and build on the social networking characteristics of dentists..
ID: Could the new social networking tools help to disseminate research findings and reach a consensus on practice patterns?
DK: I am not aware of the full use of the new social networking tools in dentistry.. However I believe the practice based research networks funded by NIDCR are creating communities of communication with practitioners who are committed to evidence-based practice, use the same language and who raise questions in a way that is highly relevant to their practice characteristics. Collectively they are acquiring data, reviewing the analyses, and commenting on the reports. They have created It is a social community of thinkers and users. I think that that movement, which is driven by questions, is avery effective way to accelerate research findings into practice.
Other ways to explore social networking – is to build on the ways that dentists like to learn. In other words, through forums that fit within their work schedule. Most dentists like to get information in their offices, within their study club, through continuing education courses, or at annual meetings.
ID: It seems there has consistently been a gap between the private practice community and the public health community. Are you seeing that change? If so, what are the drivers of that change?
DK: The gap between the public health and private practice communities is one that exists in all fields, not just in dentistry. This may not be as much a “gap” as a difference in the audiences that reflect each community’s focus of effort. One is focused on the public and patients that come to the dental office. The other focuses on the community that often cannot afford to visit a dental office. Interventions and programs used to serve these two audiences result in a “gap.”
I am seeing some aspects of this gap change, due to necessity and hard, collaborative work among organizations. Changes occur at times of crisis and urgency in particular.
We are a small profession with a big responsibility. All of us in dentistry need to work effectively toward the goal of overall oral health, and to be united in our work with other health profession colleagues.
ID: What are dentistry’s greatest challenges in the next 5 to 10 years, and how do we turn those into opportunities?
DK: One of the greatest challenges/opportunities for dentistry is ensuring the profession is proactive in positioning and supporting oral health promotion, disease prevention, and oral healthcare within the national evolution of health and healthcare. This requires aggressively promoting and implementing proven prevention programs, and moving forward with a common voice across the profession. This voice must be loud and strong.
ID: These proven prevention programs include varnishes, school based programs, nutrition, and those kinds of efforts?
DK: That’s right. Also, for many years physicians have been trained to enhance their communication skills, because so much of their work is related to counseling effective clinical and self-care practices. In fact their ability to communicate is tested as part of their board examinations. That is one of our challenges—to what degree we can enhance the dental profession’s capacity to be better communicators, to enhance the oral health literacy of their patients, as well as the caregivers for children or the elderly, and even broadly to the community.
ID: Lack of access to dental care is typically cited as a major issue, and many solutions have been posited. One concern that is always acknowledged, but rarely acted on, is funding streams to Medicaid for dentist reimbursement. What is underlying dentistry’s inability to be successful in securing more reasonable reimbursement rates in the public programs?
DK: We know that reimbursement rates are just one factor supporting improvements in access to dental care. Other factors—administrative burden, delayed reimbursements, eligible populations placing a low priority on oral health related to other life needs—also have been mentioned. A comprehensive approach is needed to address the needs of populations served by public programs. It requires documenting the effects of care “not provided” due to insufficient coverage and reimbursement. It also requires continual education of Medicaid providers, the dental profession, and the public.
ID: Is it because public policy today is influenced as much by emotion, and less by science, than in days past? Is the public simply confused?
DK: Perhaps, but for both the public and policy makers we need to provide continual clear communication and education, education, education.
ID: If you could change one thing about dentistry in the United States, what would it be?
DK: I would like to see organized dentistry’s scope of leadership for oral health expanded. This would include a more formal role for the profession to support enhanced oral health roles of other dental team members, other health providers, and the public.
ID: Probably the biggest change in healthcare came in the form of federal legislation, some of which affects dentistry. What is your perspective on the dental provisions in the healthcare reform package, and how will that affect the delivery and financing of dental care?
DK: Ensuring the presence of dental provisions in the Affordable Care Act is a real accomplishment. The imperative now is to ensure that funds are appropriated to address this authorizing legislation and support successful implementation of the dental provisions. The provisions of this Act place delivery and financing of dental care within a much broader landscape. The following areas of the Act are ones that I am particularly excited about:
Children are given priority: Specifically, the law has integrated oral health services for children in the state exchanges, including coverage for preventive services.
Prevention is highlighted: The requirements include support for oral health disease prevention, a public health education campaign, and increased infrastructure for public health programs.
School-based programs are highlighted: This reflects the profession’s opportunity to be where the children learn and play; a place where dentistry has had many successes in the past. This includes required grants for school-based dental sealant programs in allstates, territories, and Native American tribes.
Workforce flexibility and assurance: The Act includes steps to ensure sufficient faculty who are adequately prepared to meet the needs of our diverse populations with training in health literacy and cultural competence, as well as the development of workforce options and enhancements.
Accountability and assessment is built in: Actions to assess accountability include reporting of payments made to dentists, support to expand oral health surveillance systems, and requirements for participation by all states in the National Oral Health Surveillance System.
ID: Looking at the political landscape today compared to when this bill was passed, do you have any comment on the potential for changes in policy directives as we try to implement a law as wide-ranging as this?
DK: I think that this Act has clearly stimulated and affected people in two extreme ways—those who are really want to move forward with some form of health care for everyone, and others who have a concern about the way in which the Act is crafted and describes implementation. I believe the dental profession must stay fully committed to implement the Act and the provisions for oral health as presented -- and also move forward with a plan for adult dental care coverage.
ID: What frontiers are left for you and where are your next challenges?
DK: The next frontier for oral health is the integration of oral health, not only among the health professions, but also across the educational, social service, private, and policy sectors.
From a School of Public Health perspective, I see an opportunity to integrate oral health into public health training and beyond; working with other disciplines to benefit oral health. From our school’s location—on a land-grant institution of higher education rather than an academic health center—I see the daily involvement and contributions of engineering, business, humanities, agriculture, journalism, and natural science to health improvements. I am particularly proud that our school is home to the Herschel S. Horowitz Center for Health Literacy, the first academic center devoted to health literacy. The early research in this center, under the leadership of Dr. Alice Horowitz, includes critical work in oral health literacy. There is much work to do, and I plan to contribute in any way I can.
About the Interviewee
Dr. Kleinman is the Associate Dean for Research and Academic Affairs and a professor at the University of Maryland School of Public Health. A board-certified specialist in dental public health and a former Chief Dental Officer of the United States, her research has included epidemiologic studies of dental, oral, and craniofacial diseases, oral cancer, and HIV-related conditions. She participated in the development of several Surgeon General reports and was the co-executive editor of Oral Health in America: A Report of the Surgeon General, published in 2000. Dr. Kleinman has a particular interest in enhancing the understanding and elimination of health disparities, with a focus on the role of factors that transcend health conditions such as health determinants, health promotion interventions, and health literacy.