Nurturing Human Connections
Personalizing Oral Health with Advanced Technology
Sean G. Boynes, DMD, MS; Board of Directors, Harmony Health Foundation
Tina Saw, DDS; CEO, Oral Genome
Significant health care changes often come from deeply human moments. These moments happen when we prioritize empathy, personalized care, and the specific needs of people. This story takes a journey towards sparking such transformative change in oral health care, with a focus on people with disabilities.
It all starts with a heartwarming encounter I saw at Kansas City International Airport Gate B48 involving a Delta Airlines flight attendant, a father, and his son. And it highlighted the urgent need for a health care system that enhances the human experience. Through this story, we’ll explore the profound impact of personalized care and the seamless use of technology. We’ll also shed light on the challenges and opportunities we face in our mission to provide fair and inclusive oral health care for everyone.
An Inspirational Meeting
I watched as a father and son, both passionate Kansas City Chiefs fans disembarked their plane with faces filled with pure joy. The father, in his early 60s, beamed with happiness– that profound feeling when your child forms a deep connection with someone else, revealing new insights into their world. A flight attendant stood beside them, radiating warmth and kindness. It quickly became clear that she was engaged in tactile sign language–a form of sign language that involved touch and movement–to communicate with the son who had sensory impairments. Even though I couldn't understand their words, their expressions, and the laughter they shared said it all. Their connection went beyond spoken language, creating a bond that would leave a lasting impact on all three of them.
Figure 1: Tactile sign language facilitates rich interactions through touch, surpassing spoken and visual language.
During those brief moments, the potential for personalized care became strikingly evident. The unique needs and dreams of individuals took center stage. The flight attendant's willingness to communicate using tactile sign language showed a deep understanding and commitment. Her sincere efforts ignited a spark within the father and son, creating a shared memory that would stay with them long after they parted ways.
This heartwarming encounter at Gate B48 sets the stage for our discussion of the fundamental need for human connection and personalized experiences within the broader healthcare system. It’s a vivid example of how human connections can promote well-being and healing.
Figure 2: Gate B48 – The same location and angle of the picture the flight attendant also captured following her personal interaction with a father and son.
As we continue in this article, we’ll delve deeper into the importance of these human connections in healthcare. Additionally, by recognizing and valuing the unique needs, desires, and aspirations of each person and finding the best way to communicate, health care professionals can provide tailored and comprehensive support. The flight attendant's dedication to accommodating the son's sensory impairments is evidence of the significance of personalized approaches that go beyond standardized services. This concept is central to our discussion of transforming the health care landscape.
A Plea for Change in Health Care
The heartwarming interaction between a flight attendant, father, and son at Gate B48 underscores the essential importance of human connection and personalized care within our health care system. This unexpected encounter serves as a reminder for us to take a closer look at how we structure our health care systems. Often, these systems prioritize efficiency, financial considerations, bureaucracy-based care, and the sheer volume of patients over the individual's needs.1-3 We find ourselves stuck in a routine of standardized procedures and medical/dental codes, where patients are reduced to passive recipients rather than active participants in their health care journeys. Reflecting on this heartfelt moment at Gate B48, we’re reminded of the profound impact that human connections, empathy, and personalized service can have. These elements extend far beyond airport terminals and resonate deeply within the health care landscape.
Individuals with intellectual and developmental disabilities (I/DD) often encounter difficulties in maintaining oral hygiene, face barriers when seeking dental care, and experience a higher prevalence of severe gum disease and untreated cavities.4 For example, a comprehensive analysis reveals that children and young adults diagnosed with autism spectrum disorder (ASD) collectively have a dental caries prevalence of around 60%, with some studies reporting rates exceeding 90%.5 This sharply contrasts with the World Health Organization's goal of achieving 90% caries-free status in children.3,5 Furthermore, individuals with ASD exhibit a combined periodontal disease prevalence of 69.4%, significantly higher than the national U.S. average of approximately 42%.5 These disparities are exacerbated by a crisis in the oral health care workforce, characterized by a notable decrease in professionals and extended waiting periods for treatment. This disproportionately affects individuals with disabilities, who face an average waiting period that is 3 to 4 times longer than those without disabilities, regardless of their insurance type.6-7 These findings are why the National Council on Disabilities (NCD) highlights the pervasive discrimination and numerous barriers faced by individuals with I/DD and calls for urgent and rapid improvements in the oral healthcare system.8-9
Equity and the Shadow of Misdiagnosis
Building on the imperative for transformative change highlighted in the preceding section, it’s crucial to delve into the topic of equity in oral health care, shedding light on how misdiagnosis and the unitization mindset are symptomatic of broader systemic issues that demand our attention and reform.
In recent years, there has been a growing emphasis on equity in oral healthcare, with the goal of addressing disparities, fostering transformation, and ensuring fair and accessible oral health care for everyone. While incorporating equity into oral health systems holds the potential for positive change, it’s essential to carefully consider the unintended consequences that may arise when a population is treated as a single entity. Sometimes health organizations and researchers tend to "unitize" different individuals or groups under a common label, a concept akin to counting smaller groups within a larger one, as we see in math and business. However, this unitization mindset can have harmful effects on physical, dental, and mental health services, often resulting in a phenomenon known as diagnostic overshadowing ((DO).10-11 DO occurs when individuals with disabilities don’t receive timely and appropriate treatment because their symptoms are incorrectly attributed to their disability. This can lead to biased treatment plans, over- or under-treatment, and even contribute to reduced life expectancies for people with I/DD.11
The repercussions of DO extend beyond medical care and impact the perception of individuals with disabilities in various aspects of life, including their sexuality and access to services like vision and dental care.12-15 Unfortunately, misconceptions about the need for specialized equipment or training often deter professionals from providing care to people with disabilities. However, studies have shown that, in many cases, individuals with disabilities can receive the same level of care as non-disabled patients without requiring additional resources or facilities. It’s time for us to dismantle these barriers and ensure that everyone receives the quality health care they deserve.
Promoting Personalized Healthcare to Revolutionize Oral Health
As we move forward in our exploration, it becomes evident that the path to addressing the equity issues highlighted earlier and mitigating the shadow of misdiagnosis involves a transformative shift towards personalized health care—an approach that not only recognizes individuality but actively empowers individuals to participate in their own well-being. In order to bring about a transformative shift in the struggling oral health care system, it’s essential to adopt an adaptable and dynamic approach that prioritizes personalized care. This approach tailors health care to the specific needs of individuals while also addressing the unintended consequences of institutionalized equity. In this envisioned future of oral healthcare, the seamless sharing of data among dental institutions, regulatory bodies, and health care systems puts patients in control of their own information. This, in turn, streamlines processes, reduces administrative burdens, and improves the coordination of care.
Figure 3: A shift from traditional dental care to personalized health care.16-18
Personalized oral health care holds great promise for enhancing the well-being of individuals with intellectual and developmental disabilities. This approach involves making treatment decisions that consider each patient's unique circumstances, such as socioeconomic status, cultural beliefs, and access to healthcare.19-20 Actively involving patients and their caregivers in the decision-making process boosts their confidence in managing their health and understanding the benefits of behavioral changes, leading to long-lasting improvements in their health.19,21
Empowering patients to understand the underlying causes of their conditions and motivating them to work towards desired outcomes fosters a strong commitment to positive behavioral changes. Techniques like personal coaching and motivational interviewing have proven effective in this context.22-23 As we strive to instigate enduring behavior changes and enhance oral health outcomes, personalized care emerges as a beacon of potential. By tailoring healthcare decisions and interventions to meet the unique needs of individual patients, personalized care empowers individuals to actively participate in their own well-being.
Technology Enhancing Personalized Healthcare
In our exploration of personalized healthcare, it becomes evident that technology plays a crucial role. Let's now focus on how the integration of technology complements a people-centered approach. Emerging technologies like salivary testing and enablement apps, along with smartphone-based photography for oral disease detection, serve as key components.
Salivary testing offers immediate data-driven insights into oral health, enabling proactive disease prevention and early detection, which are essential aspects of personalized health care. Studies have shown that the composition of the oral microbiome, consisting of various microorganisms in the mouth, can be measured through saliva.24-25 What's even more intriguing is that we can rapidly analyze how our immune system responds to harmful pathogens in our mouth using this method as well as determine disease risk in an objective way. Furthermore, a recent scoping review highlighted that "Salivary biomarkers have the potential to revolutionize the field of dentistry across all dental disciplines as a vital element for personalized workflows."24
Smart toothbrushes not only enhance oral hygiene but also collect valuable data on brushing habits, enabling tailored recommendations that align with the unique needs of each individual.26-27 Moreover, employing artificial intelligence-powered image analysis of teeth for caries detection via smartphones significantly bolsters personalized healthcare. By simply capturing images of their teeth, individuals can promptly assess their oral health status with the help of artificial intelligence, facilitating early detection and personalized prevention strategies in the comfort of their own homes.
As shown in Table 1, these technologies, along with virtual care and coaching, empower individuals to actively participate in their oral healthcare journey, monitor their progress, and make informed decisions. Virtual health coaching entails collaborating with individuals and caregivers in a reflective and imaginative process that motivates them to optimize their personal and professional capabilities. This process aims to encourage the adoption of healthier lifestyles by fostering awareness and empowerment.28-29
Health coaching provided by oral health professionals has shown positive outcomes, including behavior changes such as a 0.4%-0.8% reduction in HbA1c levels for diabetes, whereas traditional health education did not produce similar results.29 It has also led to improvements for individuals in assisted living facilities regarding the use of fluoride, oral health support, gum disease management, and approximal cleaning.30 A scoping review has determined that health coaching techniques, including motivational interviewing, significantly impact oral health outcomes, behavior change, and professional-patient communication.31 However, it's important to note that while virtual coaching holds great promise, it is still in its early stages, and further piloting and research are necessary.
Table 1: Change agent technologies to enable personalized healthcare in oral health.
Challenges and Advocacy in Advancing Person-Centered Care
As we advocate for the transformative potential of person-centered care, it’s crucial to acknowledge the challenges associated with implementing this approach on a broader scale. While technology integration holds promise, it also requires a strong framework for data privacy and security to protect sensitive patient information. Additionally, the financial aspects of transitioning to person-centered care models, which include the adoption of new technologies and specialized training, require careful consideration and changes to current reimbursement practices. In the healthcare industry, resistance to change may exist due to established norms of standardized procedures and a fee-for-service (FFS) model. It’s also important to address concerns about overmedicalization and the potential reduction of human interaction and empathy in health care delivery when heavily relying on technology. To address these challenges, a financial model that prioritizes person-centered care and success with prevention is needed.17
Understanding the role of technology, let's explore policy recommendations for transformative change in oral health care. Policymakers should prioritize a hybrid reimbursement model that combines fee-for-service (FFS) and value-based care (VBC). This approach seeks to strike a balance between personalized, person-centered care and fiscal challenges. In this model, FFS retains its place, while VBC places emphasis on prevention, early intervention, and patient education to reduce the costs associated with acute disease treatment.32-33
Value-based incentives play a critical role by rewarding health care providers for achieving positive patient outcomes. Quality metrics assess performance, and financial rewards are provided for improving oral health and increasing patient and caregiver satisfaction. Risk-sharing agreements distribute financial responsibilities among payers, providers, and patients, promoting collaboration. The integration of telehealth enables virtual consultations and remote monitoring, improving accessibility to care. An emphasis on preventive care offers financial incentives for early interventions. A person-centered approach empowers patients to actively participate in their care, and data-driven analytics inform reimbursement policies, aligning with personalized care and enhancing patient experiences.17 These recommendations aim to prioritize personalized care, preventive measures, and equitable access to high-quality oral healthcare while addressing financial constraints.
Conclusion
In conclusion, the heartwarming encounter at Gate B48 is a powerful illustration of the transformative change needed in our health care system. It vividly demonstrates the profound impact of personalized care, human connection, and empathy in the healing process. Embracing human experience and harnessing technology can reshape our health care landscape, making it more inclusive and person-centered. The journey towards transformative change begins with recognizing the unique needs, desires, and aspirations of every individual. It involves breaking away from standardized procedures and codes, prioritizing connection over the number of procedures occurring, and placing patients and caregivers at the center of their healthcare journeys.
As we move forward, let's remember the dedication of the flight attendant and the profound connection between the father and son. These moments serve as beacons of hope, inspiring us to redefine health care beyond a narrow focus on ailments and toward a holistic consideration of what truly matters to people. By doing so, we can create a health care system that values individuality, promotes well-being, and empowers patients to actively participate in their own health, ensuring that no one is left behind on the path to better oral health and overall well-being.
References:
Watt, Richard G. "Oral health inequalities—Developments in research, policy and practice over the last 50 years." Community Dentistry and Oral Epidemiology (2023).
Watt, Richard G., Renato Venturelli, and Blánaid Daly. "Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream." British Dental Journal 227, no. 1 (2019): 49-54.
Boynes SG. Don’t say special needs, it hurts people with disabilities. Pittsburgh Post-Gazette. August 22, 2022.
Anders, Patricia L., and Ellen L. Davis. "Oral Health of Patients with Intellectual Disabilities: A Systematic Review." Special Care in Dentistry 30, no. 3 (2010): 110-117.
da Silva, Simone N., Thais Gimenez, Raquel C. Souza, Ana Claudia Mello-Moura, Daniela Prócida Raggio, Sandra Morimoto, Juliana S. Lara, Gabriela C. Soares, and Taís de Souza Tedesco. "Oral Health Status of Children and Young Adults with Autism Spectrum Disorders: Systematic Review and Meta-Analysis." International Journal of Paediatric Dentistry 27, no. 5 (2017): 388-398.
Pennsylvania Coalition for Oral Health. Access to Oral Health Workforce Report Part II, 2022.
Boynes SG. Changes: Building a Sustainable and Happy Oral Health Workforce. Presentation at the West Virginia Oral Health Coalition Annual Conference. August 25, 2023.
National Council on Disability. Policy Brief: Dental Care for IDD Report. https://ncd.gov/publications/2017/dental-issue-brief Accessed 8 Aug 23.
National Council on Disability. Incentivizing oral healthcare providers to treat patients with IDD. https://ncd.gov/publications/2023/incentivizing-oral-healthcare-providers-treat-patients-IDD Accessed 8Aug 23.
Sussman, Steven, Shanna K. Kattari, Lourdes Baezconde-Garbanati, and Shari N. Glackin. "Commentary: The Problems of Grouping All Adversity into a Special Populations Label." Evaluation & the Health Professions 43, no. 1 (2020): 66-70.
Hallyburton, Alexandra. "Diagnostic Overshadowing: An Evolutionary Concept Analysis on the Misattribution of Physical Symptoms to Pre-existing Psychological Illnesses." International Journal of Mental Health Nursing 31, no. 6 (2022): 1360-1372.
Kim, Eunjung. "Asexuality in Disability Narratives." Sexualities 14, no. 4 (2011): 479-493.
Shah, Sam. "‘Disabled People Are Sexual Citizens Too’: Supporting Sexual Identity, Well-being, and Safety for Disabled Young People." In Frontiers in Education, vol. 2, p. 46. Frontiers Media SA, 2017.
Li, Jessica C., Kenneth Wong, Andrew S. Park, Timothy R. Fricke, and Anthony J. Jackson. "The Challenges of Providing Eye Care for Adults with Intellectual Disabilities." Clinical and Experimental Optometry 98, no. 5 (2015): 420-429.
Pennsylvania Coalition for Oral Health and Achieva. Count me in: Building inclusive dental practices for patients with disabilites. https://paoralhealth.org/webinar/count-me-in-building-inclusive-dental-practices-for-patients-with-disabilities/ Accessed 08SEP2023.
Simmons, Leigh Ann, C. D. Drake, MPA Tracy W. Gaudet, and Ralph Snyderman. "Personalized Health Planning in Primary Care Settings Personalized health planning can be operationalized as a health care delivery model to support personalized, proactive, patient-driven care."
Lee, Hyewon, Natalia I. Chalmers, Avery Brow, Sean Boynes, Michael Monopoli, Mark Doherty, Olivia Croom, and Lilly Engineer. "Person-centered care model in dentistry." BMC Oral Health 18, no. 1 (2018): 1-7.
Singh S. Get personal: Building a hyper-personalized care strategy. Avia Insights. https://aviahealth.com/insights/get-personal-building-a-hyper-personalized-care-strategy/ Accessed 10SEP2023.
Suh, Jina, Spencer Williams, Jesse R. Fann, James Fogarty, Amy M. Bauer, and Gary Hsieh. "Parallel journeys of patients with cancer and depression: Challenges and opportunities for technology-enabled collaborative care." Proceedings of the ACM on Human-computer Interaction 4, no. CSCW1 (2020): 1-36.
Silness, John, and Harald Löe. "Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition." Acta odontologica scandinavica 22, no. 1 (1964): 121-135.
Wurcel, Victoria, Americo Cicchetti, Louis Garrison, Michelle MA Kip, Hendrik Koffijberg, Anne Kolbe, Mariska MG Leeflang et al. "The value of diagnostic information in personalised healthcare: a comprehensive concept to facilitate bringing this technology into healthcare systems." Public health genomics 22, no. 1-2 (2019): 8-15.
Wilder, Rebecca S., and Kimberly S. Bray. "Improving periodontal outcomes: merging clinical and behavioral science." Periodontology 2000 71, no. 1 (2016): 65-81.
Agrawal, A., and A. Gupta. "Exploring the factors influencing the choice of oral care products: A review on personalized approach." Int J Oral Dent Health 6, no. 2 (2020).
Paqué, Pune N., Christopher Herz, Joël S. Jenzer, Daniel B. Wiedemeier, Thomas Attin, Nagihan Bostanci, Georgios N. Belibasakis et al. "Microbial analysis of saliva to identify oral diseases using a point-of-care compatible qPCR assay." Journal of clinical medicine 9, no. 9 (2020): 2945.
Belibasakis, Georgios N., Nagihan Bostanci, Philip D. Marsh, and Egija Zaura. "Applications of the oral microbiome in personalized dentistry." Archives of Oral Biology 104 (2019): 7-12.
Goyal, C. Ram, Ralf Adam, Hans Timm, Julie Grender, and J. A. Qaqish. "6-month randomized controlled trial evaluating a novel smart-connected oscillating-rotating toothbrush versus a smart-connected sonic toothbrush for the reduction of plaque and gingivitis." Am J Dent 34, no. 1 (2021): 54-60.
McKenzie, Kate W., and Iain A. Pretty. "Connected toothbrushes: Bridging the gap to personalized oral health." American journal of dentistry 31, no. 3 (2018): 115-120.
Amini, Reza, Christine Lisetti, Ugan Yasavur, and Naphtali Rishe. "On-demand virtual health counselor for delivering behavior-change health interventions." In 2013 IEEE International Conference on Healthcare Informatics, pp. 46-55. IEEE, 2013.
Cinar, Ayse Basak, Ruth Freeman, and Lone Schou. "A new complementary approach for oral health and diabetes management: health coaching." International Dental Journal 68, no. 1 (2018): 54-64.
Johansson, Isabelle, Cristina Joy Torgé, and Ulrika Lindmark. "Is an oral health coaching programme a way to sustain oral health for elderly people in nursing homes? A feasibility study." International journal of dental hygiene 18, no. 1 (2020): 107-115.
Chunda, Remus, Peter Mossey, Ruth Freeman, and Siyang Yuan. "Health Coaching-Based Interventions for Oral Health Promotion: A Scoping Review." Dentistry Journal 11, no. 3 (2023): 73.
Boynes, S. G., L. Davis, G. Adams, M. Mills, and M. Deutchman. "MORE care: narrowing the rural interprofessional oral health care gap." Boston: DentaQuest Institute (2017).
Kanan, Christine, Sean Boynes, Kelli Ohrenberger, Mary Bayham, Rebekah Mathews, Danielle Apostolon, Caroline Mcleod, and Eric Tranby. "A Learning Community That Aims to Change Oral Health." (2021).