Oral healthcare for active duty and veteran populations
Originally published December 2020 on https://broadcastedge.blogspot.com/
Whine and oral health are always a predictable pairing.
The prediction is easy because the world continues to believe oral healthcare is a luxury. Oral health is not a luxury; it is a medical necessity with ongoing unmet issues worldwide.
Let's call ourselves whiners. Dental and oral healthcare are pretty straightforward, the ability to standardize and qualify dental care and oral healthcare delivery is at our fireplace mantle, and the ability to get it right for militaries is within reach.
Unfortunately, dental and oral health care remain the luxurious extra on the world's wish list, a market item labeled for gift or bonus pay. This culture persists worldwide, despite dental and oral care being a medical necessity. This culture affects military health priorities, and this culture provides unspoken approval to overlook oral healthcare needs.
Culture change can be energized with refresh lists, lists void of luxury assumptions. A new list should also be handed to military oversight.
Let's not over-complicate dental and oral health issues for the world, nor for the world's militaries. Dental and oral health should be provided as basics, incorporated into medicine, and structured as the world improves oral health structure.
Oral health wellness, emergency care and oral health trauma care should be ongoing improvements for militaries, with international agreements on care delivery standards. Research should have integrity to quality. Biomedical innovation for oral health should be an international effort tied to efficiency. Funding oral healthcare is cost effective, and advancing oral health should be relatively straightforward. Let's get the job taken care of, the right way, with quality to our work.
1. Dental and oral healthcare for the public is a medical necessity.
The culture that continues to place dental and oral healthcare as a luxury is outdated, unprofessional and disingenuous. It is beyond time for world health, private payers, medical communities and governments to include dental and oral healthcare in medicine.
* Acknowledge the health and science of dental and oral medicine. Health benefits of proper dental care are clear, even with unknown correlation directions between some physical conditions and dental care. Psychological benefits are also clear (1,2). The science of dentistry as medicine should be supported with access inclusion, in primary care assessments, in insurance inclusion and in public health regional reports.
* Clarify distinctions between dental health and oral health consistently healthcare, and in worldwide use. If culture change would benefit from enveloping dental health into oral health, with oral health leading the medical specialty into integrated processes, make the change.
* Create consensus to labor, staff and dentistry requirements. Labor and staffing should be of global consensus, including scope of practice and international requirements (3). Labor in the dental setting varies widely, from dental therapists in Britain (4) to nurses in Kosovo (5). This must be better defined and tied to quality improvement. Commitments to SERVQUAL should not be overlooked (6).
* Organize oral healthcare. Oral healthcare inclusion of cancer, neurological and neuromuscular conditions, defects and oral-facial trauma (7, 8) requires formal consensus, categorization and surveillance. Diagnostic tools and value based care are another avenue in need.
* Set expectations for medicine. Medical communities should integrate dentistry and oral health into specialties. Hospitals should include dentistry at their quality improvement, patient experience and leadership tables. Primary care should include dentistry and oral health in physicals and well adult exams. Pharmaceutical associations should include dentistry and oral health at the table, and not only for antibiotic stewardship. Biotechnology associations should include dentistry in advocacy and policy. Medical schools should require syllabi that incorporate dentistry in collaborative learning. National healthcare quality improvement teams should require consistency to dentistry and staffing credentialing. Performance improvement in academic medicine and community partnerships should require specialty collaboration metrics, dental wait times, access, and outcomes. Government reimbursement should enforce these expectations.
* Formalize metrics in oral health quality improvement during care (9, 10, 11). From utilization in Taiwan (12) to patient satisfaction in Kuwait (13) , Hong Kong (14), the United States (15, 16), Saudi Arabia (17) and Europe (18, 19, 20, 21) to Indonesia (22). Much effort has been placed in examining feasible measures in many countries, measures are necessary now, and there is no reason for further delay on consensus.
* Require consistency to oral health access metrics worldwide. What are the metrics that the CDC and other national agencies use (23), and what resources do other countries need to be able to provide similar reports? A quick view of literature focused on Latin American oral health (24, 25), China's oral health disparities (26), Taiwan oral health utilization (12) and other literature provides us insight into clear disorganization of metrics worldwide. Global health reporting (27) should partner with countries for consistency, and for resource allocation estimates. Consistency includes surveillance training and equipment. Consistency should also include access to medicine and access to oral health as conjoined metrics (28). Analyses should include consideration of medical tourism for oral health (20).
* Create global policy comparisons of where we are at and where we can be, without recreating the wheel. Policy analyses and means to improve oral health access are available (29, 30) and should be catalysts for world health cross-comparison transparency.
* Require integrity to cost and economic analyses of oral healthcare. It is widely regarded that oral healthcare is cost-effective (31, 32) , and it widely known that the world does not participate in cost-effective approach for oral health. Require health related quality of life (HRQOL) metrics to economic analyses of oral health (33).
* Refresh the energy around public health intervention consensus. What is the consensus to fluoridation (34), dental sealants and why aren't these metrics reported in global health, nor in regional health reporting annually?
* Be accountable to oral health and cancer screening has a component to dentistry well visits.
* Commit to pain severity, duration and access time to oral health provider as a reimbursement criterion, with documentation a quality audit component.
2. Dental and oral healthcare for militaries and service persons needs immediate improvement.
* Confront military total health and wellness design, and require oral health inclusion. Military health administrations continue to seek alignment in advanced designs for holistic healthcare strategy. It would be a disservice to global military leadership to settle for inferior plans; plans that exclude oral health from total health are inferior. Routine care standards, policies to ensure timely care for emergencies at home as well as emergencies during deployment, post-service and retirement routes should all be part of ongoing total health and wellness design. This could start with the inclusion of dental care in military total health agreements, such as the 4.3.1 of a recent NATO document (35). This confrontation could also be responded to with assertive inclusion of policy requirements to oral health emergency specialists during deployment.
* Require formal epidemiology for oral health in military medicine reports. Count and type of many dental emergencies in service, count and type of dental emergencies during deployment, count and type of oral maxillofacial trauma during deployment and at home, use of private and military associated specialists, staffing and labor by military, utilization of retirees, utilization of veterans, family and child dental metrics (36), etc.
* Request mutual leadership for evidence based medicine. National and global oral health specialists, surgeons and dentristry should provide quality to evidence based practice guidelines alongside military health administrators. This work not is not limited to one country; it serves worldwide. Studies on use of dental prosthetics for Indian service persons (37) can serve the population of India and populations worldwide. Studies on Armed Forces College complex fracture delivery for oral medicine can benefit all, not just Bangladesh (38). The type and nature of publications themselves can provide global insight on quality points in need of addressing.
* Request mutual leadership for evidence based medicine with military considerations. Where are the guidelines for oral trauma, metrics associated with quality to care and how can these be strengthened for military deployments? Ongoing insight into trauma, such as comprehensive French military analysis (39), could be included in structured systematic review toward evidence and policy. Guidelines for specialty considerations that affect military operations worldwide could also be shaped, such as literature inclusion of Saudi military deep diving insight (40) within systematic review. Additionally, specialist training could be developed with these partners and funded for labor supply based on the evidence and need.
* Standardize fitness for duty oral health requirements. Literature is available from many countries and military units, from South African oral health fitness for duty insight (41) to U.S. reservist disparities (42) to comparison of NATO fitness tools to unscheduled dental visits during deployments (43). It is time to get it right, consistent and rooted in routine. Voluntarism, background and socio-economic status all matter in oral health fitness for duty and health equity goals should be outlined. Understanding early dental and oral hygiene needs are enhanced with studies of military students, such as a recent study from Senegal (44). These studies could reach long term, with potential to help shape long term deployment insight as well (45). Additionally, fitness for duty readiness standards may have potential to shape culture for countries not yet acclimated to routine dental resources.
* Coordinate oral health science and innovation to prioritized, tiered funding for biomedical innovation, with military collaboration across borders. The science is specific, the innovation applications may be specific, and funding should be efficient.
* Be accountable to service person customer service. Determine what service persons want and need from oral health and dentistry. Agree on satisfaction tools for metrics, make these tools available and follow up consistently.
* Be accountable to service person oral health access. Determine the staffing numbers for labor supply, the evidence in correlation to satisfaction and outcomes, and how this can be aligned across borders (inclusive of labor credentialing and titles). Standardize measurement tools, be publicly transparent about wait times and targeted well appointments (46, 47) and include quality metrics to the total health and medical reports.
* Be accountable to veteran oral health access. Utilization metrics and comparison to oral health specialist recommendations are not consistent. Quality to these metrics remains unclear. Records reviews of veteran oral healthcare may provide evidence for opportunities in service delivery, as was the case of a Russian study (48), yet there is opportunity for real-time data to drive real-time management change. In the United States, it is illogical and confusing that the numbers of veterans served through VA medical care vary so differently than the numbers of veterans served with dental care (49, 50). Further, the mismatch on veterans who are provided dental care is not aligned with service delivery research mission. How could so much funding for insight into physical correlations miss the mark on dentistry and oral health? And how could so much funding around interventions, such as smoking cessation, be provided when there is little to no consistent, tandem care for oral health (51)? Processes around veteran dentist access projections do not follow cost and economic analyses, and processes around veteran dentistry and oral health budgets do not follow the best practices of integrated medical delivery. If funding for delivery was tied to integrated oral health, such as cancer screens and dentist well visits, funding for health service research would have automatic improvement to integrity. Open up access and normalize evidence integration to shape service delivery, even if it is contracted. Care navigation shouldn't be a charitable need (52), it should be driven by real-time analytics of need. Integrity requires accountability.
* Match veteran oral health interventions with overall oral health intervention inclusion. Small studies on VA long term care, VA infection prevention work and VA antibiotic stewardship are helpful; larger, systematic approaches should be the goal (53, 54, 55). Health insight and interventions should be applied across borders, inclusive of various health payer systems, and appreciative of military veteran status.
* Prioritize dental health veteran equity. If there is some evidence that veterans do not place emphasis on oral health wellness (56), and other evidence that oral health racial disparities exist in VA (57), where are the ongoing data analyses and interventions? Where is this research in other countries, regardless of mandated armed forced recruitment?
* Be accountable to veteran satisfaction. Standardize satisfaction tools consistent to service person and public measures.
* Fund staffing, labor and education appropriately. A service person in another country will likely be provided routine blood pressure management consistent with international science. This same service person will likely not be provided the same dentistry, and it is unknown if the added oral health components (screening, education) will be included.
* Determine public health expectations across borders, current discrepancies and ongoing metrics to assess for intervention needs. This includes fluoridation and dental sealants for military families away from their home countries.
* Commit to veteran and military service person pain severity, duration and access time to oral health provider as a reimbursement criterion, with documentation a quality audit component.
Common sense should not be depleted around a culture that views dentistry as luxury. As this culture shifts worldwide, militaries should step up in leadership.
3. Get smart and internationally coordinated on oral health research.
* Prioritize biomedical innovation research funding. In a time of competitive funding, medical specialties should do what they can to partner in global scientific advancement. This is true of oral health, and true of dentistry. Biomedical innovation in dentistry, bone, jaw and oral maxillofacial needs, as well as oral cancer screening diagnostics, should be reviewed. Innovation potential, prioritization and efficiency to research are all improved with international commitment.
* Determine publication quality standards in dental and oral health, including reference to systematic review, literature review, minimizing bias, accounting for null data, and attending to other basics for quality of publication. Be proactive with PRISMA (58) and consider AMSTAR for quality as well (59).
* Create standard definitions for measures for quality. Have international consensus with SERVQUAL (60). Have consensus to additional metrics in literature, too. In example, workload, utilized in research from a Tertiary Medical Center in India, should be defined (61) and considered for global inclusion.
* Determine methodological requirements for quality criteria for dental clinical trials (62). Build from recommendations on analytics in literature, as well. In example, consideration to improve code consistency, identified in a Finnish military oral trauma study (63), should be acknowledged, with consensus sharpening the data analytics.
* Advance military and non-military oral health collaboration with continuous health service delivery and ongoing literature reviews. A country's insight into the disparities of the two groups, including recent Indian work (64), could provide goal-setting of which international peer support may advance.
* Advance policy work. In example, dental health promotion and oral health education are common research foci and are also found to play a significant role in oral health wellness. International work, including at Iranian military centers (65) should be compared and considered in global health campaigns, international policy comparisons, expectations and funding.
* Commit to prioritization of biomedical and integrated medicine research approaches for pathologies associated with pain severity, duration and diagnostic failures. Commit to prioritization of dental at the neurological and medical table, and commit to better research toward treatments for issues like trigeminal neuralgia.
Research priorities create vast portfolios for our world's medical professionals. Dental and oral health are already isolated. Creating cohesive strategy for dental and oral health research is strategic and benefits all.
Let's not over-complicate dental and oral health issues for the world, nor for the world's militaries. Dental and oral health should be provided as basics, incorporated into medicine, and structured as the world improves oral health structure.
Oral health wellness, emergency care and oral health traumas should be ongoing for militaries, with international agreements on care delivery standards. Research integrity to quality is necessary. Biomedical innovation for oral health should be an international effort tied to efficiency. Funding oral healthcare is cost effective, and advancing oral health should be relatively straightforward. Let's get the job taken care of, the right way, with quality to our work.
Let's call ourselves whiners.
Traveling with the Refs:
1. https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Oral-Health
2. https://www.who.int/bulletin/volumes/83/9/editorial30905html/en/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162558/
4. https://www.nature.com/articles/sj.bdj.2010.209
6. https://ijme.mui.ac.ir/article-1-1248-en.html
7. https://www.who.int/news-room/fact-sheets/detail/oral-health
8. https://www.who.int/health-topics/oral-health/#tab=tab_1
9. https://www.fdiworlddental.org/resources/policy-statements-and-resolutions/quality-in-dentistry
10. https://onlinelibrary.wiley.com/doi/full/10.1111/idj.12453
11. https://onlinelibrary.wiley.com/doi/full/10.1111/idj.12481
12. https://www.sciencedirect.com/science/article/pii/S1726490116302490
13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926580/
14. https://bmcoralhealth.biomedcentral.com/articles/10.1186/s12903-018-0477-7
15. https://www.sciencedirect.com/science/article/abs/pii/S0002817714642860
16.
17. https://www.mjhs-mu.org/?mno=68754
18. https://www.tandfonline.com/doi/abs/10.1080/00016357.2016.1177661
19. https://europepmc.org/article/med/29754157
20. https://bib.irb.hr/datoteka/907112.18_Kesar_Mikulic.pdf
21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797242/
22. https://www.atlantis-press.com/proceedings/hsic-17/25885830
23. https://www.cdc.gov/oralhealth/pdfs_and_other_files/Oral-Health-Surveillance-Report-2019-h.pdf
24. https://onlinelibrary.wiley.com/doi/abs/10.1111/cdoe.12379
25. https://pubmed.ncbi.nlm.nih.gov/29700842/
26. https://onlinelibrary.wiley.com/doi/abs/10.1111/cdoe.12394
27. https://journals.sagepub.com/doi/abs/10.1177/0022034517750572
28. https://link.springer.com/article/10.1186/s12889-019-6590-y
29. https://hpi.georgetown.edu/oralhealth/
30. https://jdh.adha.org/content/91/1/6
31. https://journals.sagepub.com/doi/abs/10.1177/0022034517750572
32. https://journals.sagepub.com/doi/abs/10.1177/0022034515589958
33. https://www.scielo.br/scielo.php?pid=S1806-83242020000200604&script=sci_arttext&tlng=pt
34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6195894/
35. Doherty, G., Knight, E.C., Dobreva-Martinova, T. 2019 “Defence Team Total Health and Wellness Strategic Framework” Technical Report, NATO. Ottawa, Canada: NDHQ.
36. https://academic.oup.com/milmed/article/178/7/816/4243591
37. https://www.sciencedirect.com/science/article/abs/pii/S0377123720301635
38. https://www.banglajol.info/index.php/JAFMC/article/view/41033
39. https://academic.oup.com/milmed/article/180/5/578/4161839
40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685277/
41. https://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0011-85162017000100006
42. https://www.scirp.org/html/1-1890272_79078.htm
43. https://academic.oup.com/milmed/article-abstract/184/3-4/e148/5233895
46. https://apps.dtic.mil/sti/pdfs/ADA556277.pdf
47. https://www.tricare.mil/CoveredServices/Dental
48. https://journals.eco-vector.com/1682-7392/article/view/50053
49. https://www.va.gov/dental/
50. https://www.va.gov/healthbenefits/resources/publications/IB10-442_dental_benefits_for_veterans.pdf
51. https://www.hindawi.com/journals/ijd/2019/3419805/
52. https://www.aafp.org/afp/2020/0415/p452.html
54. https://www.sciencedirect.com/science/article/pii/S089718971830421X
55. https://www.ingentaconnect.com/contentone/ascp/tscp/2020/00000035/00000012/art00008
56. https://www.tandfonline.com/doi/abs/10.1080/07448481.2018.1540985
57. https://www.ingentaconnect.com/content/wk/mcar/2016/00000054/00000011/art00007
58. https://www.sciencedirect.com/science/article/abs/pii/S0300571220302177
59. https://onlinelibrary.wiley.com/doi/abs/10.1111/ipd.12414
60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6243813/
61. https://www.sciencedirect.com/science/article/abs/pii/S0377123718301229
62. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0190089