Dr. Nader Nadershahi, Chair of the American Dental Education Association: Benefits of Integrating Oral and Medical Care

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development, and healthcare explore new innovations and approaches. I’m your host Van Ton-Quinlivan, CEO of Futuro Health. Among the many ideas for improving the healthcare system that received a boost during the pandemic is the integration of oral health with primary medical care. This issue came to the fore as public health officials were trying to find ways to increase vaccination rates, and there’s a good reason why: there are about thirty million Americans who visit their dentist annually who do not have similar contact with their primary care provider.

Here to tell us more about that interesting area of possibility and to discuss other trends in providing care, educating practitioners and meeting workforce challenges in the profession is Dr. Nader Nadershahi, a dentist and Dean of the University of Pacific’s Arthur A Dugoni School of Dentistry. He and I also served as governor’s appointees to the California Healthcare Workforce Education and Training Council. Before becoming Dean in 2015, he held many teaching and leadership roles at the school in his long tenure there. Dr. Nadershahi earned a doctorate degree in education and an MBA, both at the University of Pacific, and is a fellow of the American College of Dentists among several other professional societies. He just became chair of the board of the American Dental Education Association. Thank you so much for joining us today.

Dr. Nader Nadershahi: Well, thank you for having me, Van. It’s a privilege to be here, and more importantly, it’s a privilege to get to know you as we do our work on the Health Workforce Education and Training Council here in the great state of California.

Van Ton-Quinlivan: The concept of interprofessional education in health sciences is a significant trend that will affect the workforce today and in the future, and one of the promises of interprofessional education  is that once healthcare professionals begin to work together in a collaborative manner, patient care will improve. I was wondering if you can explain more to our listeners about the importance of interprofessional education, and how you see that collaboration amongst dentistry and other health specialties?

Dr. Nader Nadershahi: Thank you for that question. You know, we tend to be a little more familiar with intraprofessional collaboration where we work with providers within our disciplines and patients are coming to us whether it’s mental health, oral health, or other health professionals, but the concept of interprofessional has been gaining interest. There are some groups nationally that have been working on this. There’s the Interprofessional Education Collaborative and there’s other groups that are looking at how through collaborating — learning with and from each other in the different professions — we can actually make an improvement to the health of the public and the individuals that we serve.

So, this idea of interprofessional education is taking hold through all of our disciplines, and dentistry is a very important part of that.  As you mentioned in your introduction about the thirty million Americans that will go see their oral health care provider but not see their medical provider, there are issues around diabetes, hypertension, there’s some oral cancers and other areas that maybe would be missed, and a patient’s life and longevity could really be compromised if we’re not getting them into the healthcare system. So, the more we bring our providers together, and put the patient at the center of the conversation and get them the care and the access that they need, I think it’s only going to help not only improve healthcare outcomes, but frankly lower our costs of healthcare delivery throughout the United States.

Van Ton-Quinlivan: Nader, I was wondering what brought you into dentistry and what is the type of person who should consider a career in dentistry?

Dr. Nader Nadershahi: Well, my path going into healthcare started as many of our healthcare providers. As I was going through my education, growing up here in California, I went and did my undergraduate education at the University of California Berkeley. My brother was involved with dentistry and was getting interested in that. I was looking at different parts of healthcare delivery and the combination of the art and science of what we do, the surgical components.  Maybe a little bit more on the personal side, I was studying integrative biology and art, so I like doing a lot of sculpture and working with my hands and this combination of the scientific foundation but the artistic part of what  we do as dental surgeons really sparked an interest for me in addition to obviously the work that we do to improve the health of the public. So, that’s a little bit of my personal story.

Van Ton-Quinlivan: Oh, that’s a wonderful story, and especially for all of us who are thinking about our own children or nieces and nephews, and what possible careers there are in the future. Thank you for sharing your path to your career. Let’s talk a little bit about oral health. What does that refer to, and how does oral health relate to the overall health and well-being of a person? You alluded to it a little bit in your introduction, but I’d love for you to give more examples.

Dr. Nader Nadershahi: Oral health is an area that — through a lot of the research that’s occurring and conversations that are happening at the state, national, and international levels — we’re talking more about. Oral health really has to do with the health of all the structures related to the oral cavity, the head and neck area where we tend to do most of our work. I like to say that the mouth is the window to the rest of your body. There are a lot of areas and illnesses where we can actually see some changes initially in the oral tissues.

In addition to our ability to help diagnose and prevent inflammation, some of the areas of evidence that are really starting to grow are the linkages between oral conditions — especially periodontal disease with gum disease and inflammation — to other severe chronic illnesses, including diabetes, heart disease, stroke. These infections could have an effect on outcomes for diabetics, outcomes for other patients if they’re having cancer surgeries or other treatment where poor oral health condition actually decreases the patient’s ability to heal appropriately and have the kinds of outcomes we want and may lead to more complex procedures. There’s even linkages with periodontal disease and risks with preterm delivery for pregnant women as well.

In terms of the connection between oral and overall health, the joke is “I’m gonna go see my dentist, or I’m gonna go see my medical provider.” But the mouth is part of the body, and it’s all connected, right? So, the more folks start to think about what that means for their health…if you’re taking care of your oral health, you’re actually helping reduce your need for more medications when it comes to diabetes, or potentially having more drastic surgical or other interventions in the rest of your body.

Van Ton-Quinlivan: You bring up a good point. Most of us think about going to our dentists in a very siloed way. We don’t think it’s connected to the rest of our physical well-being. I was wondering, in the philosophy that you’re bringing up, is it being reflected in the way that dentists are being trained right now?

Dr. Nader Nadershahi: It is. It’s really growing. In my role as Dean here at University of Pacific’s Dugoni School, it’s something that we have been putting into the curriculum, our integrated curriculum, and growing the medical foundation and the linkages. But at the national level, this is an important discussion as well. You know, there are some other examples of why this is important. If you just want to look at the financial impacts on this country, we have roughly two million visits to emergency departments that happen many of which could have been prevented if the individual had seen their oral health care provider to prevent the need for them to end up in the emergency room.

If we look at the cost of that, that’s estimated to be a little over $1.7 billion. So, think of the expenditures that we have and how we can reduce them by bringing these providers together. We want our students to understand their important role, and also the relationships they have with other medical providers — mental health providers, others in the community — where they can really put the patient at the center and make the right referrals. We can also educate our colleagues, who may be physician assistants or nurses or physicians or in other disciplines, that when they identify an oral health condition to then get them into the system where we could help the patients as well.

Van Ton-Quinlivan: I was wondering if you could share what are the challenges and opportunities in the dental professions right now? I’m sure there’s a number of areas where there are shortages.

Dr. Nader Nadershahi: As the population in the United States and the population in California continues to grow, some of the challenges we have are being able to provide equitable access to healthcare and oral healthcare, especially in the rural areas and rural communities where there isn’t as high of an availability of providers. That’s one area. The other area is within the profession, we have challenges with having the right number of providers. So, dental assistants being available to enhance the care that we provide, dental hygiene is at the right level of training, we have a shortage in practitioners that are available to be able to serve the needs… so we do have some workforce issues. We’re looking at ways of addressing that through expanding opportunities for education and looking at different models, but there are some core issues that we’re dealing with.

We’re looking at some innovative models as a school and as a university to help address that and bring folks together as are others that I collaborate with on the national level, whether it’s through the American Dental Education Association or another group. I’m privileged to be a member of the Santa Fe Group where we’re looking at catalyzing changes in oral healthcare throughout this country. These are models that we want to continue to test and push.

Van Ton-Quinlivan: I was wondering if you could break down the workforce development issue. You mentioned shortages in dental assistants, hygienists, and maybe the dentists themselves. Is it an interest in these occupations that is sort of the first issue, or is it the capacity of seats and the affordability of these programs? Where do you see the pipeline breaking down?

Dr. Nader Nadershahi: That’s a great question and as we’re starting to see the data, I think it’s a combination. For some of the programs — like for dental assistant training programs or even for some of the dental hygiene programs — there’s some capacity issues there. But there also is the other side, which is the interest…continuing to show why this is such a wonderful and rewarding experience. We just had the privilege of welcoming our new students and we had our white coat ceremony at the Palace of Fine Arts and were talking to them about the impact that they will have as oral healthcare providers, whether it’s a dental hygiene student, or a dental student, or our international students that are that are coming in.

I think if we have kids from K through 12 start seeing the impact that they can have in healthcare — in all the disciplines and oral health care being one part of that — that will help improve that capacity, and frankly, it’ll help to diversify all of our health professions, which we need to do. We know that we need to make our healthcare providers reflect the communities that we serve, and we’re not there yet in many disciplines, including dentistry. So, the more we can reach out and raise the bar and visibility for the value of the profession — and what it can do for you as an individual, what it can do for your family, what it can do for your communities and the impact you can have — I think that’ll help us diversify our professionals as well.

Van Ton-Quinlivan: As you’re doing this work — to establish the value of the profession in the community and the impact that you can have — you’ve been also rethinking the pathway that students should take. You mentioned some work that you’re doing at University of Pacific but also at the national level. I was wondering if you could share with us what are these best practice models that you’re working on.

Dr. Nader Nadershahi: One of the projects that I’m really excited about is the work that we’re doing in Sacramento. When it comes to the interprofessional education and the collaborative care that we talked about, there have been some really nice models in practice where providers are coming together to provide integrated care with the patient at the center, coming into one area or going out to the site. We’re looking at developing a unique — and hopefully a model that will be replicated and improved upon throughout the country — of bringing these learners together in a collaborative teaching clinic. We’re going to be developing a collaborative teaching clinic where there’s a shared electronic health record, and where medical students, physician assistant students, nursing students, dental students, pharmacy students are all coming in together — again, with the patient at the center — and looking at what are that patient’s needs and how can we best serve it.

We’ll then do some research on that and see if are we able to address the triple aim or quadruple aim, now that we’re talking about with value-based care throughout this country. I really believe this is going to be the future of how we train our healthcare providers in all of our fields.

Van Ton-Quinlivan: This sounds like a really smart approach to the practicum. When the pandemic hit, so many providers in all areas of care had to figure out how to deliver some of it via telehealth/telemedicine, but also instruction via the tele format. I was wondering whether some of those practices were adopted in the dental training area?

Dr. Nader Nadershahi: That’s a great, great question. As the pandemic hit, there was this national weight that went on everybody’s shoulders, especially in education and healthcare delivery, and I’m just so incredibly proud of the folks here at the Dugoni School at University of Pacific, but also nationally what everyone did, to pivot exactly as you’re saying.

The shift towards delivering more content online — doing student assessments using technology, but also shifting towards telehealth and some of the models that are being tested throughout the states — grew out of some of the work that was done here for about a dozen years by faculty and some of the leaders of our Pacific Center, which is now called the Pacific Center for Equity and Rural Healthcare. So, that eased the transition into telehealth and being able to provide screenings and reach out to patients in a way that they felt comfortable with, and then if they needed care, to be able to bring them into the clinic for care to keep them out of emergency rooms.

It even applies to something that maybe you wouldn’t think about with orthodontics. Our orthodontic department and the residents started shifting towards telehealth appointments because they can continue their treatment without there being a lapse, or maybe having some relapse in the movement of the teeth and the smiles that they’re developing, by using telehealth. So, there’s some really creative approaches that were taken for that to get the outreach.

At the national level, the schools were doing the same thing. As you mentioned, I’m chair of the American Dental Education Association board of directors. When the pandemic hit, I was privileged to serve as chair of our Council of Deans and the deans in the United States and Canada, we would get together every two weeks. We would talk about the challenges that are being faced and how we can support each other, and this was a conversation that was happening nationally. I’m just so incredibly proud of oral health education broadly, what our dental schools, dental hygiene programs and other schools did as well as our nursing and physician assistant and medical schools. I mean, everyone throughout the disciplines.

Van Ton-Quinlivan: When we talk to our board at Futuro Health about what will persist after the pandemic versus revert, they definitely say that telehealth is one of those things that will stay just based on consumer adoption and how consumers have enjoyed it. Do you think tele-dentistry will become a permanent part of the fabric of the delivery of oral health?

Dr. Nader Nadershahi: I think that’s a great question, and it’s one that the board and all of us should be asking, right? One, I want to say thank you for using the term telehealth because I like using that framing too, kind of with the spirit of integration. If we say telemedicine and/or tele-dentistry, we’re separating the disciplines, but with telehealth we’re actually bringing everyone together. So, I love the fact that you’re using that terminology.

I think it will be a part of what we do. Certain things we can do through telehealth. When it comes to some of the surgical care, we obviously need to have a site — whether it’s a remote site or a central site. But diagnosis and post-op discussions…there’s a lot that can be done through telehealth and I do believe that will remain as part of the training and part of the expectation, frankly, for patients because if we really want to provide equitable access to health care, we can’t expect patients from rural sites that are far away to have to make long trips to come in to receive all of their care. We have to be able to find a way to get out to them in their communities to provide that.

Van Ton-Quinlivan: So, Nader, you mentioned value-based care and actually, I would love for you to just explain the concept of value-based care, and how the opportunities that you mentioned in terms of being able to use the dental appointment to detect diabetes and heart conditions…how does that tie back into the economics of health care?

Dr. Nader Nadershahi: Yes, so…

Van Ton-Quinlivan: I give you only the hard questions.

Dr. Nader Nadershahi: You do! And I love it because that’s how we can make an impact on our community. So with the value-based care, we’re looking ultimately at how do we provide the most value. It’s not a procedure or what’s being counted that we’re actually measuring. It is the health of the patient or the health of the community, however we want to frame it. Are we improving the outcomes of care, or those health outcomes?  Are we improving the quality of that experience for the patient? And are we able to lower the costs overall of healthcare delivery?  Then the fourth piece — with the “quadruple aim” — is are we actually able to improve the quality of experience for the providers? So, through this kind of collaboration, are they more fulfilled, are they learning more and continuing to grow, and becoming better professionals and better people as they’re going through this process?

With this integrated model, we’re hoping to be able to show all of those. There’s more data coming out now — and some of the insurance companies are even starting to look at this – that shows if you spend seven billion dollars on just simple preventive oral health care to reduce inflammation, you can save seventy billion in a large population of patients on downstream diabetes care. We can decide to do real, simple, preventive work which is good for the person, but it also makes financial sense in what we’re doing. There’s more prospective studies that are happening now where we’re starting to see that.

In the recent draft of the national Physician Fee Schedule, there are more medically necessary dental procedures that are being added in. The reason why, is that for those types of procedures you can actually lower the expenditures on a national level — if you’re thinking of Medicare or other payers — because you’re doing the oral health care as part of it, and you’re not leaving that as a separate because if somebody doesn’t have coverage, they don’t get it, and that increases your costs.

That’s why I think a value-based conversation is so important.  One, it’s focused on the individual because our goal in healthcare is to prevent disease before it has any kind of an impact on the quality of life of the individuals that we serve, or on the communities that we serve. So, if we’re really focused on that, and the value is the health of the individual, then all of our work goes towards that aim. That’s, I think, why this model is so exciting.

Van Ton-Quinlivan: Well, I’m sure our listeners already have an understanding of why you are appointed by the Governor to the Health Workforce Education and Training Council for the state of California. Your knowledge of value-based care, your perspective in terms of having an integrated model of care is so important. As you bring these principles and these observations into the council, I wonder if you could talk a little bit about what insights and what actions would you want from the Council if you had a magic wand?

Dr. Nader Nadershahi: Hopefully, we both have magic wands as members of that Council. In the state right now behavioral health is a big topic, and it’s something we need to address. Whenever we’re talking about behavioral health, we should also have in the framing the overall health of the individual — which is not just mental health, but it’s their physical health, oral health, all of their access that they have in the community. I think that’s one of the magic wand pieces, is that we always bring the conversation to a higher level that’s looking at the individual and the community holistically.

The other part of this I would put in there if I had a magic wand is we talk a lot about how we finance healthcare delivery, but how do we finance healthcare education? And how are we creating a sustainable model for future generations of providers that not only continues to bring the very best and brightest to healthcare to serve our communities, but also the most diverse group, and does it in a way that isn’t going to put these large burdens of educational debt? How do we invest in that today so that ten, fifteen, twenty years from now, our children or the listeners’ children’s children will be taking advantage of it?

Van Ton-Quinlivan: In the public comments was a guest speaker from Social Finance to explain outcomes-based loans as a way to finance gap closure. It was so wonderful for us to be able to hear about that as an innovation in student financial aid programming.

Dr. Nader Nadershahi: I had a chance to have a nice conversation about that — the pay-it-forward funds and other funds that they’re developing there — and I’m hoping that we can create some other models looking at the state level and maybe at the federal level where we’re able to create commonwealth funds for health education in addition to what we can do through the lower cost or zero interest loans to help education students.  Can we actually have a large enough investment in a commonwealth fund that spins off interest that then removes the need for those students to ever have loans?  Those funds, like an endowment at a university, would be around forever, and they would touch the lives of generations because the corpus stays and the interest is what you’re reinvesting every year. Frankly, that means that we don’t have to put loan repayment programs into the budget annually and have to continue to advocate for that at the state or federal level. It’s a way that we can solve multi-generational problems by making some investments today.

Van Ton-Quinlivan: Well, I look forward to working on that issue with you on the council.

Dr. Nader Nadershahi: As do I.

Van Ton-Quinlivan: Nader, I want to make sure I give you an opportunity to talk about your work as chair of the American Dental Education Association. Is there anything that you’d like to spotlight there?

Dr. Nader Nadershahi: It’s a really special moment for the American Dental Education Association. This year, we’re celebrating our centennial since the founding of the organization. It started out as the American Association of Dental Schools and became more inclusive, and broadly now is the American Dental Education Association. It includes the United States and Canada and we have some incredible relationships with our sister organizations throughout the world, including the European Dental Educators, Southeast Asian Dental Education Group, and lots of others as well.

As we’re celebrating our centennial, I use this as an opportunity to reflect on where we want to be. So I’m really excited to be leading this project. We call it the “New Thinking for the New Century project, and we have a group of leaders and new voices from throughout our organization that are looking at what are the continuing and emerging issues that we need to look at, broadly, in dental education and oral health education to meet the needs of our students in our communities? I’m really excited about that work. We’ll be presenting that during our annual session, which will be in Portland in March.

The theme of the annual session — as chair you have an opportunity to come up with the theme — is “Believe I’m possible” and what I want every student or resident or a new faculty member or staff member throughout oral healthcare to realize is that what we have access to today — as oral healthcare educators and healthcare providers — would have seemed impossible 100 years ago. It was the individuals that came before us, the giants upon whose shoulders we stand, that have made this possible. So, I want everyone to believe that something may seem really difficult or impossible – like creating a large commonwealth fund for the state of California or federally — but when you do it and you take those steps and you look back, it was because individuals were able to believe in themselves and believe in the collaborative opportunities that are there. I’m really excited about that.

It’s a privilege to serve my colleagues. I’ve been connected here with the Dugoni School of Dentistry and University of Pacific for over thirty years, and I love what I do. Just seeing the energy that the students bring, and the impact they’re going to have on individuals lives that they’ll touch throughout their careers…I really, really can’t imagine doing anything else.

Van Ton-Quinlivan: Well, thank you so much for pushing the envelope for the industry, and also, being a coalition builder. It’s very clear that you’re able to bring so many stakeholders into the same conversation in order for us to all be rowing together. So, thank you very much for your leadership.

Dr. Nader Nadershahi: Oh, my pleasure. And thank you for the opportunity to spend some time, and thank you for the leadership you bring and for creating space for these important discussions. I really appreciate that.

Van Ton-Quinlivan: Well, I certainly learned a lot. Thank you very much for being on the podcast today.

Dr. Nader Nadershahi: Of course.

Van Ton-Quinlivan: I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.