Worcester Medicine January/February 2021

medicine worcester

Volume 90 • Number 1 Published by Worcester District Medical Society January / February 2021

Oral Health & Local Disparities “What? There’s no fluoride in Worcester’s water?” 3 Oral Health Leaders Address Oral Health in Worcester

Oral Health WDMS.ORG

THANK Y U. For the selfless commitment to patient care that Worcester-area physicians demonstrate every day, but particularly in these difficult times, we thank you.

Contents

JANUARY / FEBRUARY 2021

From the Archives

Hugh Silk, MD, MPH

Supporting the Oral Health Needs of Individuals with Mental Illness 11

Oral Health

Shari Harding, DNP

Dale Magee, MD, WDMS Curator

Oral Health and Local Disparities 5

Pharmacists as Members of the Oral Healthcare Team 12

As I See It

Editorial 4

Hugh Silk, MD, MPH Vanessa Villamarin, BS

“What? There’s No Fluoride in Worcester’s Water?” 7 Lynda Young, MD

Three Oral Health Leaders Address Oral Health in Worcester 8 Brian Genna, DMD Christine Dominick, CDA, RDH, M.Ed Stacy Hampson, RDH

Oral Health Care in Worcester: From the Dental Perspective 10 Christina Shaw, DMD Pooja Gupta, DMD

Anna Morin, PharmD

Oral Health Across Worcester’s Communities 13

Fluorine Advocated for Worcester Water 17

Baseball and Dentistry: A Lot to Smile About 18 Charles A. Steinberg, DDS

A Book Review Second 18

Morgan Groover Connor Hickey Ashwin Panda Jay Patel Aditya Vangala Michael Wang

Robert E. Bessette, MD

Oral Health in Medical Education: A Student’s Perspective 15

Congratulations to This Year’s Award Recipients 21

Olivia Nuelle

Society Snippets

2020 Medical Student Scholarship Award 19

Student-Physician Meet And Greet 22

nov/dec correction notice

In the article by Thoru Pederson, PhD two corrections have been made: The footnote on p. 5 defined the abbreviation of “Covid-19” as “coronavirus identified in 2019” which has been corrceted to “Coronavirus disease 2019” based on consensus. Lastly, on p. 6, right column, third paragraph, line 10, the word “contains” has been corrcted to “elicits”.

published by

wdms editorial board

produced by

Worcester District Medical Society

Hugh Silk, MD, MPH, Guest Editor Lisa Beittel, MBA Anthony Esposito, MD Heather Finlay-Morreale, MD Michael Hirsh, MD Anna Morin, PharmD Nancy S. Morris, PhD, ANP Thoru Pederson, PhD Joel Popkin, MD Alwyn Rapose, MD Robert Sorrenti, MD Paul Steen, MD Ram Upadhyay, MD Peter Zacharia, MD Alex Newbury, MD Resident Representative Parul Sarwal, MD Resident Representative Aly Rabin, Student Representative

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President Spiro Spanakis, DO Vice President Giles Whalen, MD Secretary Marianne Felice, MD Treasurer Dale Magee, MD wdms administration

Martha Wright, MBA, Executive Director Melissa Boucher, Administrative Assistant

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The Reliant Medical Group, UMass Memorial Health Care, Music Worcester advertising

Inquiries to Martha Wright mwwdms@massmed.org 508-753-1579

Worcester Medicine does not hold itself responsible for statements made by any contributor. Statements or opinions expressed in Worcester Medicine reflect the views of the author(s) and not the official policy of the Worcester District Medical Society unless so stated. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by Worcester Medicine unless stated. Material printed in Worcester Medicine is covered by copyright. No copyright is claimed to any work of the U.S. government. No part of this publication may be reproduced or transmitted in any form without written permission. For information on subscriptions, permissions, reprints and other services contact the Worcester District Medical Society.

WORCESTER MEDICINE

Editorial Hugh Silk, MD, MPH

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WENTY years ago, I pondered the plight of my patients’ mouths as

a young family medicine resident at Hahnemann Family Health Center. Why did so many children and hospitalized patients have poor oral health? The articles presented in this themed edition of Worcester Medicine on Oral Health focus the lens on answering that question about the origins of challenging oral health issues for so many in our region. I am honored to be the guest editor for this edition, as oral health affects so much of our systemic health and our overall wellness – heart disease, diabetes, and also job prospects and the ability to smile and show pride. I am proud of the authors herein who challenge us all to do more to help our patients and our neighbors to have better overall wellness through better oral health. Oral health matters; oral health is health. In the first article, I worked with Vanessa Villamarin, UMMS Class of 2021, to explore the origins of local disparities and their effect on oral health. Vanessa researched her piece during a 4th year oral health elective. She shares her own personal experiences and reveals the ugly truth about the “why” behind local disparities. Lynda Young, a longtime advocate for oral health in Worcester and Massachusetts, has written a review of the history of Worcester’s complicated history around community water fluoridation. Such a promising public health intervention that has been the victim of misinformation and our infatuation with liberty over communal benefit. Addressing oral health is a team sport; Brian Genna, Christine Dominick, and Stacy Hampson prove this point with their three-part article. Dr. Genna leads off paying homage to the role of the community health center in addressing local unmet needs using interprofessional care and outreach to meet people where they live. Christine Dominick explains the role that dental hygiene students can play in our community and how they have adapted to COVID-19 in their many community-based clinics. And finally, Stacy Hampson shares the unique role of the dedicated members of her team on the UMass Care Mobile serving school children and those without dental insurance around the city. Each set of providers filling important gaps and creating a tapestry of essential dental care. The Worcester District Dental Society is the sister organization to the Worcester District Medical Society. Drs. Christina Shaw and Pooja Gupta give us a brief history of the Society and the important role local dentists play in tackling our oral health challenges especially during

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the pandemic. Dentists and dental hygienists are at the highest risk of contracting the virus – kudos for your dedication! I have a special affinity for Shari Harding’s piece on the role of nursing for those with mental health disease. I provide primary care in Leominster to those with significant mental health issues. Their teeth and mouths, as Shari points out, are severely affected by the side effects of their medications, tobacco, and the uphill battle to address dental hygiene. Her call to us as medical providers to do our part is long overdue! Anna Morin continues this theme with her insightful pharmacist’s perspective on oral health and medications. She reminds us that the pharmacist is part of the oral health team and can offer advice on everything from tobacco cessation and oral cancer prevention to relief medications for canker sores. I applaud her emphasis on the role of xerostomia from medications as a major cause of caries. Six UMass students from the class of 2023 spent two weeks during their Population Health Clerkship closely examining the oral health issues faced by our most vulnerable populations. They worked with other student groups which culminated in a presentation to their colleagues and this article delving into the inequities faced by the homeless, veterans, Latinx, the uninsured and underinsured, those living with disabilities and the black population in Worcester. They offer up hope with a plea for better integrated care. Many of us have worked hard over the years to build a more comprehensive oral health curriculum at UMass Medical School. Olivia Nuelle, UMMS 2022, talks about her perspective on the curriculum and the role she herself has played in evolving it. It is clear that she is using the newly acquired oral health skills in her clerkships! Like Dr. Jane Locherie always notes – I encourage everyone to read the Society Snippets. Dr. Dale Magee has managed to find some historic references on community water fluoridation, and I offer an added plug for the As I See It section which includes a message from Dr. Charles Steinberg, a dentist and the President of the Worcester Red Sox, about bringing baseball to Worcester with oral health messaging from the mascot and team! + Hugh Silk, MD, MPH Professor, University of Massachusetts Medical School, Department of Family Medicine and Community Health and Instructor, Harvard School of Dental Medicine and Harvard Medical School

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Oral Health and Local Disparities Hugh Silk, MD, MPH Vanessa Villamarin, BS

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aking up with a right-sided headache every day made

getting ready for seventh grade a taxing chore. The bursts of pain shooting down my jaw throughout the day and night made simple tasks difficult and made concentrating almost impossible. I was having my first dental complication while experiencing a lack of access to care. No child should go through that experience. -Vanessa Villamarin

new patients, and eight are English speaking only. According to the American Dental Association (ADA), dentists in Massachusetts are predominantly white/non-Hispanic (65-70%), with <4% being Black and <5% Hispanic/Latino. This data highlights the need for a more diverse provider population and more dentists in Worcester to accept MassHealth.

why is oral health important?

dental health in the time of covid-19

Caries are the most common chronic childhood illness in the United States according to the Centers for Disease Control and Prevention (CDC). Children ages 5 to 19 from low-income households are over twice as likely (25%) to have caries compared to children from higher-income households (11%). Furthermore, among children aged 3 to 5 years, the largest racial and ethnic disparity in oral health is seen in Mexican-American and non-Hispanic Black children. Complications from untreated dental caries include infections and pain which can affect speaking, eating, and concentrating. Children with poor dental health have more school absences and receive lower grades than those with good dental health.1 These racial disparities continue into adulthood; CDC data shows that non-Hispanic Blacks and Mexican-Americans aged 35 to 44 years experience untreated tooth decay at twice the rate of non-Hispanic whites and 1 in 4 women of childbearing age have untreated caries. Notably, children of mothers who have high levels of untreated caries are greater than three times as likely to also have caries.2 Only a third of Black, Hispanic, or Asian women see a dentist during pregnancy. Compare this to their white counterparts where 50% see the dentist. What is contributing to these disparities? To be clear, there is no biological reason for Black or Hispanic Americans to have more dental pathology; this occurs due to systemic and institutional racism and bias. This is not an indictment of individuals but instead, a reflection of the flaws of our healthcare, health education system, and society. These issues impact a large percentage of our population, as Worcester’s population is 21% Hispanic/Latino, 13% Black or African American, and 21% persons in poverty.3 access to dental care in worcester

The MassHealth database reports 33 dental practices in the city of Worcester accepting MassHealth and four practices accepting Health Safety Net. However, of these 33 practices, only 18 are currently accepting

The populations at higher risk of experiencing disparities in oral health care (Black and Hispanic/Latinx) are the same populations who are disproportionately affected by COVID-19. Due to the risk of viral transmission through aerosol-generating procedures, the ADA recommended postponement of elective dental services in March 2020 and advised offices to remain closed with the exception of emergency care until April 30th. As dental offices opened, working down the backlog of preventive services for those with no dental issues, leaves the vulnerable with more serious issues waiting in long lines for care. future steps

The most common oral pathologies (dental caries and periodontal disease) are preventable. There are several strategies that we should implore locally to reduce the inherent disparities. pregnancy

Children born to mothers with caries are more likely to have caries. In addition, periodontitis has been associated with an increased risk of preterm birth, low birth weight, and preeclampsia.4-6 Pregnancy is a teachable moment. Potential initiatives could include more dental offices designating chair times for pregnant patients to ensure that they are seen by a dentist at least once during their pregnancy. In addition, prenatal oral health education should be

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Oral Health

Oral Health and Local Disparities Continued

incorporated into local health schools and residency programs to reinforce the importance of oral health during pregnancy. The American Academy of Pediatrics’ Tiny Teeth campaign includes a robust tool kit (available in multiple languages at AAP.org/tinyteeth) for healthcare professionals that contains educational and outreach materials. childhood

Dental sealants (a coating applied to molars) are an effective preventative measure; they are easily applied and protect against cavities for up to four years. They are most effective when applied soon after the permanent molars erupt (between the ages of 6 and 12). Less than half of children between the ages of 6 and 11 receive dental sealants. If dental sealants were applied in schools nationally, it could prevent three million cavities and save up to $300 million in dental costs.7 Furthermore, if this preventative approach was offered to all, this would reduce disparities in access to care. uninsured populations

The Worcester Free Clinic Coalition has some free dental services. Future initiatives could expand to providing dental cleaning services at all Worcester Free Clinics as well as oral hygiene education, free oral hygiene tools, and fluoride varnish applications. fluoride

It is well-known that fluoride is beneficial for oral health. According to the CDC, community water fluoridation (CWF) is an important component of preventing tooth decay. CWF is economically beneficial for families, saves our U.S. healthcare system $38 in dental treatment costs for every $1 spent, and reduces caries in both children and adults by 25%. Of the 132 water systems of Worcester County, 103 are not fluoridated. Ensuring that all public water systems provide fluoridation would greatly benefit our Worcester population providing inexpensive and safe prevention for all. education

Half of the population sees a medical provider in any given year but do not visit a dental provider; medical providers must be able to offer advice, examine the mouth, and make timely dental referrals. Residents, students, and faculty should learn the basics of oral hygiene, proper nutrition, and importance of dental visits. Other health professionals should also be encouraged to study the subject. Lastly, we must continue to strengthen pipeline programs for Black and Latinx students into medical, nursing, and dental programs. Societal norms must greatly evolve to increase the number of underrepresented minorities in health professions. +

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references

1. Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and performance. Am J Public Health 2011;101:1900–6. 2. Dye BA, Vargas CM, Lee JJ, Magder L, Tinanoff N. Assessing the Relationship Between Children’s Oral Health Status and That of Their Mothers. J Am Dent Assoc. 2011;142(2), 173-183. 3. “U.S. Census Bureau QuickFacts: Worcester City, Massachusetts.” Census Bureau QuickFacts, www.census.gov/quickfacts/ worcestercitymassachusetts. 4. Corbella S, Taschieri S, Del Fabbro M, Francetti L, Weinstein R, Ferrazzi E. Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association. Quintessence Int. 2016 Mar;47(3):193-204. 5. Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. ObstetGynecol 2003;101:227231. 6. Goepfert AR, Jeffcoat MK, Andrews WW, et al. Periodontal disease and upper genital tract inflammation in early spontaneous preterm birth. Obstet Gynecol 2004;104:777-783. 7. “School Sealant Programs.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 10 Sept. 2019, www.cdc.gov/oralhealth/dental_ sealant_program/index.htm. Vanessa Villamarin, B.S. M.D. Candidate Class of 2021 University of Massachusetts Medical School Hugh Silk, MD, MPH Professor, University of Massachusetts Medical School, Department of Family Medicine and Community Health and Instructor, Harvard School of Dental Medicine and Harvard Medical School

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“What? There’s No Fluoride in Worcester’s Water?” Lynda Young, MD

there is little chance of this issue passing. What’s interesting, though, is if you look up our city’s status on CWF, it states we are “partially” fluoridated since 1995. This is true, to a degree. There is a small section in our city that receives water from Holden which does fluoridate its water. Only about 250 Worcesterites benefit from this CWF. is cwf or lack thereof a serious public

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health issue? e t ’ s ta k e a l o o k at t h e h i s t o ry o f c o m m u n i t y wat e r

Fluoridation (CWF). If you Google the top public health achievements since 1900, CWF is right up there. It all started in the early 1900s. A dentist in Colorado, Dr. Frederick McKay, noticed a lot of “grotesque brown stains” on the teeth of Colorado Springs natives. Several years later, he and a colleague, Dr. G.V. Black, noted that children with “Colorado Brown Stain” were remarkedly resistant to tooth decay. It wasn’t until 1931 when Dr. McKay and other colleagues discovered that the culprit causing this staining and decay resistance was the high level of fluoride in well water in certain areas of our country. Drawing on Dr. McKay’s studies and those of others, in 1945, Grand Rapids, Michigan became the first city in the world to add fluoride to its water supply. Over the next 11 years, researchers monitored the level of dental decay in almost 30,000 school children. The caries rate in those children who were born after fluoride was added to water had dropped over 60%. This finding was a huge breakthrough in dental care and made tooth decay a preventable disease for most people. That formative event, over subsequent years, led to 73% of communities in the U.S. fluoridating their water supplies as of 2018. so, what’s with worcester?

When I began my pediatric practice in Worcester, I was taken aback by the level of significant dental decay in the children I saw. How can this happen? I asked the then Commissioner of Public Health in Worcester, Dr. Arnold Gurwitz, who said, “Well, for starters, there’s no fluoride in our water.” To which I replied, “WHAT? There’s no fluoride in Worcester’s water? How come?” “Long story,” he said. CWF in Massachusetts, as in many other states, is done on a townby-town initiative. In Worcester, the Board of Health can mandate the addition of fluoride to the city water, but the Worcester voters can initiate a ballot referendum on the mandate. This process has actually occurred four times, beginning in the 1950s. Then, it was soundly defeated as “a Communist plot” with little discussion of improving the public health of our citizens. CWF in Worcester was a ballot referendum three more times, the last being in 2001. At that time, the Health Foundation of Central Massachusetts provided a $400,000 grant to an oral health collaborative coalition to provide public education on oral health and the value of adding fluoride to the city’s water supply. This time, the opposition’s issue was “forced medication” and no one should have to take something that they have not consented to. Once again, fluoridation was defeated. Currently, there seems to be no appetite to bring CWF up again and certainly not with this method of approval. It seems, after four failures,

The lack of fluoridation in Worcester leads to consideration of the troubling inequities or disparities in oral health. Even with significant improvements that have occurred over the years, disparities exist in certain ethnic and racial groups. In the United States, in general, the poorest oral health of any racial or ethnic groups occurs in non-Hispanic Blacks, Hispanics, American Indians and Alaska Natives. The majority of reasons are social determinants of health including poverty, lack of access to health and dental care, and lack of health insurance. CWF in Worcester is a single intervention that would go a long way to close the inequities of oral health in our community. why do people oppose cwf?

Some of the reasons have been mentioned above. There are some issues that are founded in real or questionable studies. The browning of teeth, as seen in Colorado Springs, is called fluorosis, and has been consistently brought up by opponents to CWF. The level of fluoride in CWF is safely below fluorosis-inducing levels. As you can imagine, too much of a good thing can lead to problems. And fluoride is no exception. Besides staining of teeth, this mineral has purportedly been linked to all sorts of health problems: skeletal fluorosis, osteosclerosis, osteosarcoma, and other bone deformities. These findings have never been duplicated in more recent and peer-reviewed publications, or in studies examining people consuming normal levels of fluoride, but you will hear about these concerns and others any time you raise adding fluoride to the water supply. how could we expand fluoridation to

worcester, given the opposition and the previous history of failures?

One option is to replicate the state-wide initiative of making the legal age to purchase tobacco 21 years

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Oral Health “What? There’s No Fluoride in Worcester’s Water?” Continued old. As with CWF, tobacco legislation is done on a town-by-town basis. But coalitions in favor of 21 instead of 18 years of age in most towns were able to get legislators in the State House to draft a bill that eventually passed. Would this work for fluoride? It worked in Connecticut. Look, no one likes to be told what to do, many do not understand the concept of public health and given the current pandemic, this issue is way down on the to-do list. But do not despair – we will test these un-fluoridated waters in the future! + Lynda Young, MD, FAAP, Professor of Pediatrics UMass Medical School.

Thank You Dr. Jane Lochrie After serving over two decades as one of our Editorial Board members, and as Editor for nearly 10 years, sadly Dr. Lochrie is stepping down. Her tireless efforts, brilliant ideas and superb guidance produced over 120 issues, each one thoughtfully developed and always informative. On behalf of the Editorial Board, thank you for the years of dedication and commitment. You will be sorely missed.

Three Oral Health Leaders Address Oral Health in Worcester Oral Health – The Community Health Center Perspective Brian Genna, DMD

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entistry in a community health center

setting has provided me with a fulfilling career. I work with people from many different ethnic and cultural backgrounds. What I used to take for granted, like the simple task of brushing your teeth, has taken on new meaning when caring for patients that have viewed dental and medical care as a service used only for acute issues. Our mission is to help people live healthier lives. The objective is to provide high quality care and promote wellness via many different disciplines working together for the benefit of the patient. There is an interdisciplinary participation by physicians, dentists, nurses, community health workers, and other health disciplines. This model serves to provide the patient with a central health home that addresses all their health care needs under one roof. I will illustrate this concept of collaboration between departments using our pregnant population. It is common knowledge that dental education should start early. The objective is to be proactive rather than reactive; to prevent caries rather than treat caries. To emphasize this message, we have worked closely with our medical colleagues. We have established a gateway for perinatal patients to obtain a dental appointment during their medical prenatal visit. Our medical colleagues can provide immediate scheduling for their patients in the dental department. This preventative appointment is an opportunity to emphasize oral preventative care during pregnancy and carry it forward to their newborn. We review fluoride and its benefits; gingival changes during pregnancy; timing of meals and snacks; tooth brushing and flossing, teething, oral care products, and re-call schedules for children. And continuity of care extends to the newborn as we emphasize dental visits as soon as the first tooth erupts or before age one. This interdisciplinary relationship carries to other groups of patients with underlying medical conditions, such as those with diabetes. We have provided a pathway, working with our medical colleagues, to ensure that those patients are seen regularly in the dental department too. Community health dentistry has come a long way. A common misconception is that only extractions are performed. We provide dental procedures from root canal therapy, to removable dentures, and implant restorations. We cater to all ages and emphasize restoration of teeth rather than removal; our goal is not only a healthy mouth but a healthy lifestyle. Brian Genna, DMD Dental Director, Edward M. Kennedy Community Health Center

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Oral Health

Dental Hygiene Students & Their Role

Delivering Smiles to Children & Families

Christine Dominick, CDA, RDH, M.Ed

Stacy Hampson, RDH

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ass college of

pharmacy andHealth Sciences’ Forsyth School of Dental Hygiene is dedicated to caring for all diverse populations in Worcester and beyond. Our students are trained in comprehensive dental hygiene care and spend extra time with patients getting to know them, their overall health issues, and teach patients how to care for their mouth health. It is our mission to never turn a patient away for financial reasons; we charge minimal fees for cleanings, X-rays, education, and referrals, as needed. MCPHS Forsyth School of Dental Hygiene has reopened its clinic during COVID-19 and welcomed back patients. We have implemented additional safety measures to assure patient safety and continued health at each visit. In addition to our established protocols, we have reduced the number of people in the clinic at any one time and we ask all students, faculty, staff, and patients to get a COVID-19 test each day they are on campus. We do not do procedures that produce aerosols, and we are wearing additional PPE exceeding CDC Guidelines. During this time of social distancing, our students continue their work in the community by creating virtual presentations and activities highlighting ways to improve oral health for all. Please look for them at: Worcester Senior Center, Boys and Girls Club, Everyday Miracles Peer Recovery Center, Webster Square Day Care Center, Head Start, Aids Project Worcester, Rainbow Child Development Center, Southeast Asian Coalition, Bay Path Vocational Technical High School, Worcester Public Schools Transition and New Citizens programs, Coes Pond Village, Together We Grow Preschool, Veterans Inc., Charles J. Faris Recovery Center, Marie’s Mission Diaper Distribution, Training Resources of America, and the Free Medical Clinic at Epworth Church. No insurance? Remember, patients may qualify for free care on our voucher system! For more information, you or your patients can call 774-243-3410 today! Christine Dominick, CDA, RDH, M.Ed Professor of Dental Hygiene and Associate Dean Forsyth School of Dental Hygiene Email: christine.dominick@mcphs.edu

he umass memorial ronald mcdonald

Care Mobile (“Care Mobile”) was founded in August 2000. It was the first Care Mobile established in the United States through a partnership between UMass Memorial Health Care and the New England Ronald McDonald House Charities. The Care Mobile provides preventative dental and medical services to children and families, in 10 under-served, largely non-English speaking, low income communities throughout Worcester. The Care Mobile is operated by four core staff members: a Family Nurse Practitioner, Registered Dental Hygienist (who is also the Care Mobile’s backup driver), a Community Outreach Liaison, and a Clinic Coordinator – who also serve as certified Spanish interpreters, phlebotomists, and registration staff. Additional staff include four per-diem dental hygienists and part-time medical and dental directors. Services are provided on the Care Mobile regardless of a patient’s insurance status. Appointments are preferred, but walk-ins are welcome. The staff also connects children and families to medical and dental “homes.” Referrals to food banks, housing, employment, and other community resources are offered to patients. In addition to delivering direct medical and preventative dental services, we provide a dental school-based program twice a week that serves children in 22 elementary inner-city schools. Dental services include fluoride treatments, sealant applications, and dental exams. In 2019, the program provided almost 5,000 dental procedures and exams to Worcester’s most vulnerable public school children. By treating the child directly at the school, we are removing barriers to care, such as lack of transportation or a parent not being able to take time off from work. It is not uncommon to see a child with severe dental decay or a child who has never seen a dentist before. It is well understood that dental pain due to tooth decay can affect a student’s ability to function in the classroom and is one of the leading causes of absenteeism. One of the biggest challenges to the dental health of the children of Worcester is the lack of fluoridation in Worcester’s water supply. Fluoride is important for prevention of dental decay. Our future goals include expanding dental and medical services to area towns while continuing our outreach in Worcester communities of color, as well as in Worcester public schools. We will continue to strive and reach out to the most vulnerable children and their families to increase access to high quality dental and medical care, reduce health and dental care disparities, and create health equity for all. + Stacy Hampson, RDH Dental Programs Coordinator UMass Memorial Medical Center Ronald McDonald Care Mobile Email: Stacy.Hampson@umassmemorial.org

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Oral Health Care in Worcester: From the Dental Perspective Christina Shaw, DMD Pooja Gupta, DMD

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remember to brush and floss your teeth !”

this farewell from your dentist might be a wellworn joke, but in the era of COVID-19 it is worth giving deeper consideration to the sentiment. Over the past six months, daily life has been turned upside down and routines we’ve long taken for granted are no longer recognizable. During these stressful times, it’s important to remember that oral health is an essential component of both physical and mental well-being. Studies have repeatedly shown the relationship between tooth decay and gum disease with broader illnesses, such as diabetes and heart disease. At the same time, lack of confidence in one’s smile can undermine self-esteem and further exacerbate other stressors. I bring this up because a national spike in cracked teeth from “pandemic stress” has made front page news across media outlets, from CNN to Fox News, and dental office closures this spring led many to miss cleanings and checkups. My colleagues and I can attest that we have seen this phenomenon firsthand and are concerned about the ongoing impacts these stressors and disruptions are likely to have as we head into winter. It’s within this context that the Worcester District Dental Society (WDDS), an association of area dentists, has doubled down on its efforts to promote and enable top class oral health in the local community. WDDS draws from Worcester and surrounding towns, creating a formal vehicle for providers to support oral health initiatives and contribute lessons learned. On a broader scale, WDDS is a component society of the Massachusetts Dental Society founded in 1856 - which now includes nearly 5,000 Massachusetts dentists, and connects nationally to the American Dental Association. Throughout the COVID-19 pandemic, the WDDS has pivoted to support both members and the community. In the beginning of the crisis, WDDS coordinated a drop-off point for local dentists to donate much-needed personal protective equipment to the Massachusetts Emergency Management Agency (MEMA) for distribution to hospitals and healthcare

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providers in need. Local dentists turned out their supply closets to give thousands of masks, gloves, gowns, and cleaning products to frontline healthcare workers grappling with the virus in those days of uncertainty. In turn, as supply levels stabilized, the WDDS has ensured that area dentists have had access to the protective equipment needed to continue providing essential oral health care to local communities. The dentists in this district have shown immediate adaptation to telemedicine during the pandemic. In-person meetings may have changed to Zoom, but the desire to help one another and our patients remains the same. Outside of COVID-19, these networks align resources and initiatives that benefit the local community and expand care for those in need. WDDS and its members collaborate closely with other area oral health organizations, including the Massachusetts College of Pharmacy and Health Sciences dental departments and the Quinsigamond Community College dental clinic. Whether providing scholarships for promising students or enabling training opportunities for the next generation of healthcare providers in our community, WDDS has been invested in ensuring that Massachusetts remains at the leading edge of oral healthcare in the country. In line with this objective, expanding oral healthcare availability continues to be a cornerstone of WDDS’ important work. Society members helped lead the expansion of dental chairs in local federally qualified health centers, creating more opportunity for treatment. There are two community health centers in the Worcester district that provide comprehensive dental care (Dr. Genna’s article covers the Edward M. Kennedy Dental Center). The Family Health Center in Worcester now has 13 chairs and their clinic in Southbridge has four chairs. Lastly, there is a satellite Tufts dental clinic, in Worcester, that provides care to the disabled. Similarly, WDDS views school-based care as a unique opportunity to broaden access to oral health education and screening. Before COVID-19 hit, the Family Heath Center also went into the city schools for care. Year after year, WDDS continues to organize continuing education programs for the local dentists and conducts social events to bring the general dentists and specialty dentists of the district together. In the pre-COVID-19 era, nearly 75%1 of adults in Massachusetts visited the dentist in a given year and Massachusetts consistently had one of the highest numbers of dentists per capita.2 These numbers partially reflect the hard work done by providers to increase access to care. Still, work remains to be done to sustain and even further improve the oral condition of Massachusetts residents, particularly given the societal upheaval that has taken place this year. WDDS remains committed to its community, and to partnering with like-minded healthcare providers to drive positive outcomes for residents. So, remember to brush and floss your teeth! + references:

1. 2017 Massachusetts State Health Assessment www.mass.gov/dph 2. America Dental Association/Health Policy Institute 2020 https:// www.ada.org/en/science-research/health-policy-institute/dentalstatistics/workforce Christina Shaw, DMD, is a general dentist who practices at Shaw Family Dental in Holden, MA. Pooja Gupta, DMD, is the Chair of the Worcester District Dental Society.

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Supporting the Oral Health Needs of Individuals with Mental Illness Shari Harding, DNP

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e n ta l c a r e i s a s i g n i f i c a n t c o n c e r n f o r i n d i v i d ua l s

experiencing mental health conditions. Individuals with mental illness often face significant risk factors and barriers related to dental health. These challenges affect self-care and professional dental care. As healthcare professionals, nurses are uniquely positioned to leverage our existing relationships with patients to facilitate improved dental care. Nurses across care settings can influence dental outcomes among individuals with mental illness through affective and instrumental supports. Individuals with mental illness often experience risk factors that may worsen dental health. For example, many mental health medications have potential side effects such as xerostomia, sialorrhea, gingival hyperplasia, bruxism, and/or movement disorders affecting oral muscles.1,2 In addition to prescribed medications, individuals with any mental illness are more likely to use tobacco and illicit substances,3 which negatively affect dental health.1 According to the Substance Abuse and Mental Health Services Administration, 27.2% of adults with any mental illness reported current tobacco use and 38.8% reported past year use of illicit drugs.3 Excessive caffeine intake is common and contributes to xerostomia and tooth wear.4 Many of these substances also cause symptoms such as xerostomia and bruxism, as well as increasing the risk of dental caries and oral cancers.5 Importantly, oral cancers may go unrecognized without appropriate oral exams from primary care providers and routine dental care from dental hygienists and dentists.6 Individuals with mental illness experience several barriers to dental care. Barriers to self-care include experiencing mental health symptoms which can lead to self-neglect. Depression itself is a risk factor for poor dental outcomes.4 Barriers to professional dental care include mental illness stigma, dental anxiety, and access to care. The stigma of mental illness can discourage seeking care1 and even self-disclosing psychiatric medications on a dental care intake form can create discomfort for some individuals. Dental anxiety is a common psychiatric comorbidity7 and can cause individuals to delay or even avoid dental care. Lastly, access to dental care is a significant obstacle for many individuals. Dental insurance coverage, especially among adults, is highly variable. Financial constraints are most prevalent for dental care compared to other types of health care,8 with 52% of Americans citing cost and 31% citing insurance issues as barriers.9 To enhance dental outcomes among individuals with mental illness, we need to address the barriers and challenges to self-care and obtaining professional care. Health care professionals, especially nurses, across all care settings often form strong, positive alliances with patients. Being aware of common barriers to dental care (access, cost, anxiety, and recognition of need) helps us when assessing and intervening on

individual needs. Nurse-led routine brief screenings can be done within the context of nurse-patient relationships, using an open-ended question such as “Tell me about your dental and oral health needs.” Once we understand an individual’s perceived needs and barriers, we can provide additional direction through focused questions including: • “How often do you brush your teeth?” • “How often do you floss your teeth?” • “When was the last time you went to the dentist?” • “When was the last time you had your teeth cleaned by a hygienist?” When we ask direct questions, we demonstrate the importance of dental health behaviors. Affective support such as active listening and empathy helps patients to feel safe and empowered, providing the foundation for addressing health needs. Instrumental support includes responding to dental needs with information and resources. For example, we can help identify substances that may cause adverse dental effects and then help evaluate the need for continued use. Some necessary medications cause xerostomia and we can support patients with strategies to alleviate symptoms by encouraging use of sugar-free gums or candies, salivareplacements, sips of water, and sucking on ice chips.10 We can combine education with practical coaching around self-care, such as bundling brushing and flossing with more pleasurable activities such as listening to a favorite song or watching part of a favorite television program, setting reminder alarms, or putting dental care supplies in accessible places alongside other daily activities. We can also assess for and encourage patients to decrease their use of substances such as caffeine, tobacco, sugary drinks or gums, and illicit substances. To help address professional care needs, we can assist patients in finding dental providers who are sensitive to their needs and who accept their insurance or have income-based fee structures. Sharing an updated list of dental providers and assisting patients in determining which providers accept various insurances and payment methods may be the help they need. For preventive care such as cleanings, local dental provider schools may have affordable clinic options (in Worcester this includes Quinsigamond Community College and the Mass College of Pharmacy and Health Sciences Dental Hygiene Programs). Referrals to behavioral health specialists may also be appropriate to address dental anxiety and other unmet mental health or substance use

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Oral Health Supporting the Oral Health Needs of Individuals with Mental Illness?” Continued needs. The most effective referrals for patients with mental and dental health needs are “warm” referrals, with the nurse assisting in communication and regular follow-up with other providers and the patient throughout the process.11 We can follow up with a phone call, message, or other reminder to help encourage patients to take the steps needed to make and keep dental and mental health appointments. Often, it will take several discussions over time to increase patients’ readiness to engage in care. Nurses are well placed to address these gaps in dental care through their ability to partner with patients to assess and meet individual needs. + references:

1. Clark DB. Mental health issues and special care patients. Dental Clinics of North America. 2016;60(3):551-566. 2. Stahl S. Stahl’s essential psychopharmacology: Prescriber’s guide. Sixth edition. Cambridge University Press; 2017. 3. Key substance use and mental health indicators in the United States: Results from the 2019 national survey on drug use and health. Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/product/ key-substance-use-and-mental-health-indicators-in-theunited-states-results-from-the-2019-national-survey-on-DrugUse-and-Health/PEP20-07-01-001. Accessed November 6, 2020. 4. Young WG. Tooth wear: diet analysis and advice. International Dental Journal, 2005;55(2):68–72. 5. Tomar SL, Hecht SS, Jaspers I, Gregory, RL, Stepanov, I. Oral health effects of combusted and smokeless tobacco products. Advances in Dental Research, 2019;30(1):4-10. 6. Oral cancer. National Institute of Dental and Craniofacial Research. Accessed November 6, 2020. https://www.nidcr.nih. gov/health-info/oral-cancer/more-info 7. 7. Halonen. H, Nissinen. J, Lehtiniemi H, Salo T, Riipinen. P, Miettunen. J. The association between dental anxiety and psychiatric disorders and symptoms: A systematic review. Clinical Practice and Epidemiology in Mental Health, 2018;14:207-222. 8. Vujicic M, Buchmueller T, Klein R. Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Affairs, 2016;35(12):2176-2182. 9. Brody A. Cost remains barrier to dental care access. Dimensions of Dental Hygiene, 2020;18(2):9. 10. American Dental Association. Managing dry mouth. The Journal of the American Dental Association, 2016;146(2):40. 11. Tips for making trauma-informed warm referrals. Commonwealth of Massachusetts. https://www.mass.gov/ info-details/tips-for-making-trauma-informed-warm-referrals. Accessed November 6, 2020. Shari Harding, DNP, is an assistant professor at the UMass Medical School’s Graduate School of Nursing. Email: shari.harding@umassmed.edu

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Pharmacists as Members of the Oral Healthcare Team Anna Morin, PharmD

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he role of the pharmacist continues to

evolve from compounding and dispensing to encompass a broader range of functions relating to patient-centered care. Pharmacists serve as key members of the healthcare team, often consulted by other health professionals and the public regarding medication- and health-related questions. The American Pharmacists Association (APhA) Foundation is a not-for-profit organization committed to advancing pharmacists’ patient care services through philanthropy, research, and innovation.1 The Foundation has created an inter-disciplinary framework for pharmacists to play an active role in oral disease prevention, identification, assessment, and referral. Community pharmacists are among the most accessible health professionals and are in a unique position to disseminate information on oral health, especially to those who lack or have limited access to dentists and other oral health professionals. Levels of pharmacist involvement in the promotion of oral health initiatives include providing advice and education regarding: • Over-the-counter (OTC) and prescription oral products • Smoking cessation • Signs and symptoms of oral conditions • Referrals to and endorsement of advice from oral health professionals • The link between oral health and chronic systemic diseases • Medication adverse effects including: mouth ulcers, xerostomia, or osteonecrosis • Healthy eating with a reduction in and frequency of sugar consumption Older patients, in particular, can benefit from oral health services provided by pharmacists. These patients are often taking several prescription and OTC medications for numerous chronic diseases. Pharmacists should monitor patients’ pharmacotherapy for adverse oral health events and talk with both patients and caregivers about the relationship of oral hygiene and overall health. The Beers

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Pharmacists as Members of the Oral Healthcare Team Continued list of medications serves as an evidence-based guide for identifying the most problematic drugs that should be avoided in older adults.2 Medications, such as anticholinergics, cause dry mouth or xerostomia, which increases the volume of caries-causing bacteria and plaque and causes a more acidic pH ultimately leading to dental caries. Pharmacists can suggest to patients to talk to their providers about medications that cause xerostomia, saliva substitutes, and the use of fluoride rinses to protect teeth. As part of smoking cessation interventions, pharmacists should discuss oral health advantages of quitting smoking with tobacco users and recommend treatments that can help them stop using tobacco products. Dental pain and oral lesions are the most common reasons patients seek advice on OTC products in pharmacies. Products include topical and oral analgesics for tooth pain and oral lesions, such as canker sores, ulcerations, stomatitis, and candidiasis. Being knowledgeable about the signs and symptoms of oral cavity cancer (i.e., mouth pain; difficulty or painful swallowing; white or reddish patches inside the mouth; lip or mouth sores that do not heal), allows pharmacists to appropriately refer patients with these symptoms for medical care.3 Sugar (in the form of fructose, glucose, and sucrose) is a well-known cause of tooth decay and is often used as flavoring in liquid forms of medication, particularly those used by children. Pharmacists can support prevention of early childhood caries by suggesting and/or compounding medications containing sugar-free flavoring alternatives. Oral health is essential to overall health and quality of life. Efforts to promote oral health should be standard of care and incorporated as part of the pharmacist’s medication therapy management services for all patients. Knowledgeable, well-respected and accessible, community pharmacists are in an ideal position to team up with oral health professionals to reduce the incidence of potentially preventable oral conditions including dental caries, gum disease, and oral cancer. Ongoing education and training is important for pharmacists to provide patient-centered care in the area of oral health. +

Oral Health Across Worcester’s Communities Morgan Groover, Connor Hickey Ashwin Panda, Jay Patel Aditya Vangala, Michael Wang shown left to right

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iversity , one of worcester ’ s greatest

strengths, also poses its greatest healthcare challenge. Below we explore six key populations, each with unique oral healthcare needs. We present their current state of oral health, while commenting on hurdles and next steps. Lastly, we offer conclusions and suggest more integrated care in the healthcare system.

black communities references:

1. The American Pharmacists Association (APhA) Foundation: Oral Health Initiatives. Available at: https://www.aphafoundation. org/oral-health/our-work. Accessed November 19, 2020. 2. American Geriatrics Society 2019 Beers Criteria Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674–94. 3. Mouth cancer: symptoms and causes. Mayo Clinic. Available at: https://www.mayoclinic.org/diseases-conditions/mouth-cancer/ symptoms-causes/syc-20350997. Accessed November 19, 2020. Anna Morin, PharmD Dean, School of Pharmacy-Worcester/Manchester MCPHS University

African American (AA) children have higher rates of tooth decay and loss than white non-Hispanic counterparts. Similar disparities exist among access to preventive services, such as sealants. These disparities persist into adulthood. AA adults have the highest rates of tooth decay and are 13% less likely to keep all of their teeth over the course of their life. A 2019 systematic literature review identifies familial and structural factors that have contributed to this inequality. AAs were more likely to utilize treatments which allow for greater autonomy (brushing teeth vs. fluoride treatments). Moreover, a 2016 cross-sectional study indicated nearly half of all AA parents were unaware their children qualified for Medicaid (Como et al., 2019). Racial disparities in oral health are deeply rooted in society and will require a multifactorial solution.

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Oral Health

Oral Health Across Worcester’s Communities Continued

latinx communities

The Latinx community constitutes the majority of the Massachusetts immigrant population. Although MassHealth includes dental coverage, large disparities in dental healthcare still exist amongst populations of color. Nearly 1 in 5 Latinos do not visit the dentist. Hispanic youth receive less dental care and suffer from tooth decay at greater rates than the general population. Access to care is affected by insurance, transportation, culture, and socioeconomics. Language plays an important role too. Many people are naturally “afraid” of the dentist; compound that with not speaking the same language as everybody in the office. Although there is awareness about oral health in Latinx communities, there is a disconnect. We need more dental providers who are familiar with Latinx culture. By removing the language and cultural barrier, patients will feel more comfortable. Less than 10% of dentists in the US are Hispanic/Latinx (H/L) while 17% of the population is H/L. While solving this health disparity is complicated, increased diversity of providers would be an important step forward. homeless population

There are glaring disparities in the oral health of people experiencing homelessness. A national survey reported that 60.4% of adults experiencing poverty have periodontal disease (Eke et al., 2018). Another study revealed tooth loss and oral pain are very prevalent in older homeless adults; half of participants were missing half their teeth, had not seen a dentist in over five years, and had oral pain which affected eating and sleeping (Freitas et al., 2018). Society is failing the oral healthcare needs of our unhoused neighbors. People experiencing homelessness encounter many barriers to maintaining good oral hygiene, including lack of space and tools to brush and floss regularly. Moreover, oral hygiene falls lower on a list of priorities; most are concerned with finding shelter and food. Most homeless individuals have little control over their food origin, resulting in sugary food and drinks. Alcohol and substance use are more common, affecting oral health. Poor oral health impacts more than just their mouth. Lack of confidence over one’s smile and concern over facial appearance can be stigmatizing, isolating, and depressing. This often hinders opportunities for education, employment, and social relationships. We must ask: does poor oral health perpetuate homelessness? people with disabilities

A study of people with developmental and intellectual disabilities (DID) (e.g., autism and Down syndrome) found that 80% had periodontitis and 88% had caries. Other issues include tooth malalignment and tooth fractures due to falls. People with DID are at greater risk for tooth decay from challenges to follow proper hygiene practices. They also face other obstacles to good oral health: behavioral issues, communication problems, difficulty getting to dental practices, and use of dental chairs. Common impairments like neuromuscular problems can also complicate procedures.

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Fortunately, Worcester does have a dental clinic for treating people with DID (a collaboration between Tufts Dental and Seven Hills). However, our community needs more capacity and better cooperation between dental and medical services for this population. veterans

There are ~44,000 veterans (7% of the population) living in Worcester County. Sadly, few veterans get their dental care through the Veterans Administration (VA). To qualify for VA dental care, veterans must be former prisoners of war or incurred an oral injury while on active duty. These criteria apply to only ~7% of veterans. Compounding this, there are only four VA centers in Massachusetts proving dental care; the closest is in Bedford. During active service, veterans experience greater rates of tobacco use, carcinogen exposure, and post-traumatic stress disorder, all contributing to increased oral disease risk. So why don’t we offer more dental care to our veterans? Simple measures such as regular dental visits could prevent a huge amount of oral disease burden. There are few people more deserving of our country’s financial support than our veterans. the uninsured and underinsured

Over 6,000 residents in Worcester remain uninsured, per Blue Cross Blue Shield. MassHealth has prevented those numbers from climbing by insuring ~90,000 of Worcester’s residents. Lack of insurance leads to worse oral and systemic health outcomes, ranging from caries to diabetes. MassHealth offers a wide range of preventative and treatment benefits, including cleanings, exams, extractions, dentures, and more. But there is more to be done. Crowns and root canals can save a tooth, which can preserve a smile, self-confidence, and even job prospects. Unfortunately, coverage for these procedures is limited in MassHealth’s current dental benefits. In 2017, the American Dental Association reported a majority of MassHealth members used the emergency department instead of dental offices for dental issues, totaling $2.5 million in avoidable costs. Currently, MassHealth is promoting their Accountable Care Organization merging oral and medical care. This integration is vital to oral health equity. The end goal is to improve accessibility, convenience, and standardize quality.

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Oral Health Across Worcester’s Communities Continued conclusion

With respect to Worcester’s Black and Latinx communities, its homeless population, people with disabilities, veterans, and community members with MassHealth, it is apparent that, despite all being integral parts of our community, they do not have similar oral health outcomes to our white privately insured citizens. We need better integration of medical and dental care, increased access to care, and a diverse workforce to achieve oral and overall health equity for everyone in our Worcester community. + works cited

Como DH, Stein Duker LI, Polido JC, Cermak SA. The Persistence of Oral Health Disparities for African American Children: A Scoping Review. Int J Environ Res Public Health. 2019;16(5):710. Eke, P. I., Thornton-Evans, G. O., Wei, L., Borgnakke, W. S., Dye, B. A., & Genco, R. J. (2018). Periodontitis in US Adults. The Journal of the American Dental Association, 149(7). Freitas, D. J., Kaplan, L. M., Tieu, L., Ponath, C., Guzman, D., & Kushel, M. (2018). Oral health and access to dental care among older homeless adults: Results from the HOPE HOME study. Journal of Public Health Dentistry, 79(1), 3-9. All authors are UMMS class of 2023 who recently did their UMMS Population Health Clerkship on the Topic of Oral Health in Worcester. Morgan Groover morgan.groover@umassmed.edu Connor Hickey connor.hickey@umassmed.edu Ashwin Panda ashwin.panda@umassmed.edu Jay Patel jay.patel@umassmed.edu Aditya Vangala aditya.vangala@umassmed.edu Michael Wang michael.wang@umassmed.edu

Oral Health in Medical Education: A Student’s Perspective Olivia Nuelle

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a n y pa t i e n t s d o n o t h av e d e n t a l

insurance, a dental home, or access to dental care. And yet, oral health is important. It is linked to systemic health and can exacerbate chronic diseases, such as diabetes. Many oral health conditions are preventable and treatable. Dental caries, the most common chronic childhood disease, are preventable with proper oral hygiene and dental care. However, many patients are unable to see a dentist regularly for a variety of reasons, making it important that physicians are trained in the basics of oral health in order to properly serve their patients’ needs and successfully collaborate with dental providers. Many medical schools do not have robust oral health curriculums. Yet, the Institute of Medicine and other national organizations promote the important role that medical providers play with regards to a patient’s oral health care. Through the hard work of oral health champions working at medical institutions, there has been a push to better teach oral health and weave it throughout curriculum. University of Massachusetts and many other medical schools have put a renewed emphasis on teaching preventative care and social determinants of health. The mouth and oral cavity are an important window into the overall health of a patient and an integral component to health maintenance. Adding oral health topics into medical school curriculum ensures that students are taught about the importance of oral health care and its impact on patients’ overall health, and further integrates social determinants of health and preventative care into clinical medicine. During the summer between my first and second year of medical school, I worked with Dr. Hugh Silk to catalog areas where oral health is taught in the curriculum at University of Massachusetts and identify areas of the curriculum to further integrate oral health information. The goal was to make sure that critical oral health topics like childhood caries, oral manifestations of common infections and diseases,

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above

Screenshots from the series of Step 1 review videos shared on YouTube.

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Oral Health in Medical Education: A Student’s Perspective Continued

and the effect of oral health on systemic disease were included in the curriculum. We identified areas where oral health topics were pertinent to material already being taught. The goal was to have a longitudinal oral health curriculum woven through the four years of medical education. Through collaboration with each course director and utilization of validated national curriculum like Smiles for Life, we were able to increase the amount of oral health topics in the curriculum and further emphasize the importance of this information with regards to patients and their well-being. Smiles for Life has modules and quizzes that cover all aspects of the oral exam, oral health maintenance, and oral health in all ages of patients. Using a validated curriculum is a great way to make sure that important information is being taught and taught well. We also created some of our own educational material in the form of PowerPoint lectures and independent learning modules. We created a series of Step 1 review videos with Dr. Sachs specifically covering oral health related topics and how they show up on the Step 1 exam (https://12daysinmarch. com/oral-health-topics/). At University of Massachusetts, during the clinical years, there are oral health elective rotations and interstitial days. These interstitial days are a great example of the longitudinal nature of a well-implemented oral health curriculum. The entire third year class attends these days full of various lectures on topics deemed essential to supplement the learning done in clinical rotations. Oral health lectures are woven throughout the interstitial curriculum and nicely build off information taught in the first two years. There is a component of review, and there is a clinical component which pairs well with the clinical learning we do in our third year. The oral health interstitial time we have had so far has been engaging and thought-provoking. The lecturer was passionate and knowledgeable about the topics discussed and was able to relate them to clinical care and discuss the impact that oral health has on patients.

In my third year so far, by using the oral exam in my clinical encounters, I have been able to get a better picture of the health of my patients. In pediatrics, the number of teeth a toddler has can give insight into their development. I had a long conversating with a 10-year-old about how excited she was for braces and the pride she takes in her teeth. Having these conversations allows physicians to lay the groundwork for proper oral hygiene and healthy habits that children can carry through their lives. In adults, the oral exam is an important screening tool to get a sense of their home health maintenance and can open conversations about access to care. These conversations allow a physician to consider more than a patient’s chief health concern and provide comprehensive care. As a student, I do not expect to graduate medical school as a specialist in any field; however, I am expected to complete a thorough neurological exam and assessment. I also am expected to complete a thorough oral health exam and assessment. After all, the mouth and oral cavity are just as much a part of the body as the nervous system. Through our mouths we eat, communicate, breathe, smile, and laugh. It is a complex and important piece of our overall wellbeing as humans. Going forward, I hope that oral health information will continue to become a standardized and consistent component of medical education. There are many great national resources available and educational tools that can be integrated into medical curricula. When students start learning about oral health early in their medical education, it will no longer feel like an additional piece of curriculum, but rather an essential piece of the whole. Oral health is a critical aspect of a person’s overall health; therefore, it is an essential part of medical education. + Olivia Nuelle, M.D. Candidate at University of Massachusetts Medical School olivia.nuelle@umassmed.edu

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From the Archives

Curator B. Dale Magee, MD

curator’s note:

Up until 1967, the Worcester Medical News also reported for the Worcester Dental Society.

Worcester Medical News Volume XV, 5, January 1951. Pg 5

Worcester Medical News Volume XVI, 8, April 1952. Pg 16

Fluorine Advocated for Worcester Water

Shrewsbury Votes to Fluoridate

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he Worcester District Dental Society acted on December 13, 1950 to renew a recommendation made by the society one year earlier that fluorine be added to the water supply of the city of Worcester for the purpose of decreasing dental caries. This action is based on previous action of the American Dental Association and the Massachusetts Dental Society. Fluoridation of the public water supply was recently approved by the Massachusetts Department of Public Health and was recommended by that department to the city of Worcester in a letter this month. The relation between fluorine and tooth decay has been under constant study since 1931. For the past 10 years, a series of controlled experiments have observed the results of the artificial addition of sodium fluoride to city water supplies in a number of cities. Some such cities are Grand Rapids, Michigan, Sheboygan and Madison, Wisconsin, Evanston, Illinois and Newburgh, New York. Recently published reports of these experiments and city wide studies point to a reduction of tooth decay from birth in those exposed to fluoride waters by more than 1/2. Approximately 20% of early teenage school children that are exposed have been rendered carries free. Worcester water now contains 1/10 of a part per million of fluorine. Artificially raising this level to one part per million would in no way affect the taste, odor, or other qualities of the city water supply. No deleterious side effects are known to occur as a result of such fluoridation of water supplies. The public health committee of the medical society considered this matter December 13 and unanimously approved recommending it for the society action at the next meeting of the medical society in January. +

t the town meeting, March 17, 1952, Shrewsbury voted to have its water department fluoridate its water supply, in accordance with recommended practice, as a dental public health measure. The cost of installation of equipment will be approximately $4000 which was also appropriated The proposal had the support of all the dentists and physicians present and is in line with the stand taken by the Worcester District Medical Society and the Worcester District Dental Society. It is hoped that the children born after fluoridation of the water supply will have 50% to 60% less dental caries then at present. +

Worcester Medical News Vol. XXV, 9, May, 1971. Pg 3

Look Ma, No Cavities

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recent editorial position by the Worcester Medical News, favoring fluoridation of the city’s water supply, has stimulated expressed opposition and upon reflection leads one to conclude that there is considerable emotionalism related to the subject. For example, some feel that since the city voted against fluoridation in the past, then the subject should not be resurrected. Another example of emotional reaction to the subject, is a cartoon advertisement in a recent issue of the Worcester Yank depicting an anxious face with a glass of water forcefully positioned at the mouth in the caption, “DON’T LET THEM FORCE FLUORIDES DOWN YOUR THROAT.” There are other countless examples of extremely negative reaction generated by the subject. The only one positive reaction from the opponents, which agrees with the proponents, is that fluoride significantly reduces dental decay. It is for this public health reason that fluoridation of the city’s water has been ordered by the Health Department. It is the Health Department’s duty and obligation to recommend and implement measures which will improve and maintain the health of our citizenry. We should look to our public health officials with confidence. Fluoridation is not a political issue, nor should it be an emotional issue, but a calculated decision based on the documented objectively analyzed scientific data. +

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As I See It

Baseball & Dentistry: A Lot To Smile About

A Book Review Second

Dr. Charles A. Steinberg

Robert E. Bessette MD

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45-year baseball career is the number of curious glances I receive when people discover that my nickname, “Dr. Charles,” refers to my doctorate in dentistry. How, they ask, did I go from oral health to our National Pastime? “Ahhh,” I say, using my patients’ old expression as they “opened wide.” Baseball actually preceded dentistry. In my native Baltimore, I was exposed to my father’s profession—orthodontia— and the care, credibility, and responsibility that came with it. It was appealing. But a funny thing happened on my way to dental school. My high school, Gilman School, arranged senior year internships that allowed this baseball nut to work for his beloved Baltimore Orioles. Heaven. At 17, I had peaked. And the Orioles allowed me to extend my stay. It became an unexpected annual summer job, through undergraduate and dental school—both at the University of Maryland. But I knew, with dentistry beckoning, my days with a baseball club were numbered. I just didn’t know how big a number it would be. In my sophomore year of dental school, I had my “Eureka!” moment: “I’ll become the Orioles’ team dentist!” I knew them; they knew me. And they said yes! Thus, began my plunge into sports dentistry. My doctoral thesis analyzed mouthguards: stock, mouth-formed, and custommade. The Orioles allowed me to measure their performance with and without protective mouthguards. No, it wasn’t double-blind or conclusive, but it was a thrilling dive into dental academia. I taught our players about the dreadful, deadly hazards of smokeless tobacco. And I studied traumatic injuries—from collisions to being hit by the pitch. Attending seminars at the University of Michigan and University of Texas, I became a founding and charter member of the Academy for Sports Dentistry—the only dental student! As I started private practice, splitting time between the ballpark and the operatory, our young energetic club counsel picked me to operate a new kind of scoreboard—a Diamond Vision videoboard. That lawyer was Larry Lucchino. I immersed into my baseball work with Larry while keeping dentistry part time. Exhausting. Delightful. After creating Oriole Park at Camden Yards, Larry took over the San Diego Padres—and took me with him! After 10 years of part-time practice, I gave up chairside dentistry to become Vice President of the Padres. But I continued to promote oral health—to players and to fans. Seven years later, we joined the Boston Red Sox, where our promotion of oral health included “Tooth Days at Fenway.” And so here we are, proud to be bringing a ballclub to a sparkling new home for our community. Imagine players teaching us to brush, floss, and avoid tobacco. Imagine our mascot, Smiley Ball, providing toothbrushes and toothpaste to all who show their smile. Imagine the WooSox recognizing community dentists who ensure that young athletes wear protective mouthguards. We imagine. And we would love to. Maybe we will turn Polar Park into Molar Park. And where better to do so than in the birthplace of the smiley face? + n amusing part of my

Charles A. Steinberg DDS, President of the Worcester Red Sox 18

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r. joel popkin recently favorably

reviewed Sande Bishop’s latest work “Stalking the Doctors of the Full Moon,” a review of the preserved minutes of the Union Medical Association, physicians of the Blackstone Valley 1834-1845. May I also add an enthusiastic second. These physicians labored in a vacuum before any knowledge of physiology or appreciation of germ transmission. Despite this deficit, the minutes reflect a commitment to learning more about the medical and surgical issues confronting them as well as the frustration of not being able to accomplish more. Interestingly, their concerns regarding quest of knowledge and desire to better the lives of patients are similar to issues facing us today. They also struggled with the issue of “alternative medicine” and expressed compensation concerns. Each of the meeting notes were analyzed by the author with concise, insightful, and often humorous remarks that help shed light on the issues of the day. Biographical reviews, prevailing economic and societal issues further frame the atmosphere in which these early physicians labored. This latest contribution to our local history by Sande Bishop deserves the attention of the membership. In addition to the historical value, one will also appreciate the command of the English language and the prose employed by these physicians. I thoroughly enjoyed the book and would enthusiastically encourage our membership to join me in appreciating this most recent excellent contribution by someone we fondly remember. + Robert E. Bessette MD, Infectious Disease Division, St. Vincent Hospital

WORCESTER MEDICINE

Society Snippets

WDMS Fall Meeting WDMS FallDistrict District Meeting Tuesday, October 20, 2020 Tuesday, October 20, 2020 2020 Medical Student Scholarship Award Recipients 2020 Medical Students Scholarship Award Recipients

Alec R. Allain

University of Massachusetts Medical School Dr. Herbert E. Nieburgs Scholarship Award

Stephanie Craig

Lake Erie College of Osteopathic Medicine Paulette Griffin Pugnaire Book Award

Thomas J. Kania

University of Massachusetts Medical School MRMC John A. Rauth Book Award

Kendall J. Burdick

University of Massachusetts Medical School Joyce Cariglia and David Williams Book Award

Brennan P. Dagle

University of Massachusetts Medical School UMMHC Dr. Samuel Pickens Scholarship Award

Kara J. Kennedy

University of Massachusetts Medical School Dr. Herbert E. Nieburgs Scholarship Award

Kimberly P. Burke

University of Massachusetts Medical School Dr. Burte Guterman Scholarship Award

Tamika T. Isaac

Philadelphia College of Osteopathic Medicine Dr. Herbert E. Nieburgs Scholarship Award

Laura O. Knapik

University of New England College of Osteopathic Medicine Dr. Lillian AE Luksis Scholarship Award

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Catherine G. Cattley

University of New England College of Osteopathic Medicine Worcester District Medical Society Scholarship Award

Kelsey G. Jones

University of Massachusetts Medical School Dr. Herbert E. Nieburgs Scholarship Award

Cindy A. Le

University of Massachusetts Medical School Dr. Gilbert E. Levinson Scholarship Award by the SVH Medical Staff

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WORCESTER MEDICINE

Society Snippets

2020 Medical Scholarship Award 2020 MedicalStudents Student Scholarship AwardRecipients Recipients (Continued) Continued

Marc J. Poirier

Ryan M. Saliga

Lake Erie College of Osteopathic Medicine Dr. Julius Tegelberg Scholarship Award

Rebecca Toohey

Creighton University School of Medicine Physician’s Insurance Dr. Najmosama Nikrui Book Award

University of Massachusetts Medical School Dr. Sanfrey Lilyestrom Scholarship Award

Vanessa N. Villamarin

University of Massachusetts Medical School RMG Dr. M. Elizabeth Fletcher Scholarshiop Award

Michelle R. Shabo

University of Massachusetts Medical School Dr. Leonard J. Morse Scholarship Award

ToQuynh T. Vu

University of New Englad College of Osteopathic Medicine Worcester District Medical Society Scholarship Award

Nathan B. Taber

University of Massachusetts Medical School Amaral Family Book Award

Mina Zaky

Tufts University School of Medicine Dr. Herbert E. Nieburgs Scholarship Award

Please Help Support the Next Generation of Physicians

PleaseItHelp Support the Next of Physicians is your generous support thatGeneration makes this scholarship program possible It is your generous support thatevery makesyear. this scholarship program possible every year.

Your tax deductable contribution, in whatever amount, will allow tax deductable whatever amount, will allow us toYour continue thiscontribution, WDMS intradition of giving to

us to continue this WDMS tradition of giving to help support the next generaton of physicians.

Visit oursupport new website: wdms.org and click green box To help the next generaton of the physicians Visit our new website: www.wdms.org and click the green box

To view the Fall District Meeting Ceremony wdms.org/past-events

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To view the Fall District Meeting Ceremony JANUARY / FEBRUARY 2021 https://www.wdms.org/past-events/

WORCESTER MEDICINE

Society Snippets

Congratulations To This Year’s Award Recipients Congratulations to This Year’s Award Recipients MMS/WDMS 2020 Community Clinician of the Year

(Formerly known as the Wisteria Award)

Dr. Timothy B. Hopkins

Dr. Paul M. Steen

The Community Clinician of the Year Award was adopted at the Interim House of Delegates meeting in November of 1998. It was established to recognize a physician from each district medical society who has made significant contributions to patients and the community.

The Editor’s Award reconizes Editors for their outstanding contributions to the Societies publication of Worcester Medicine, formerly known as Worcester Medical News.

2020 Career Achievement Award

2020 Editor’s Award

30th Annual Dr. A. Jane Fitzpatrick Community Service Award

Dr. Jeffrey L. Geller

Dr. John P. Broach

The Career Achievement Award was established to honor a WDMS Member who has demonstrated compassion and dedication to the medical needs of patients and or the public and has made significant contributions to the practice of medicine.

This Dr. A. Jane Fitzpatrick Award was established by WDMS to commemorate the life-long contributions and exemplary efforts of Dr. Fitzpatrick. The award recognizes a member of the health care community for contributions beyond professional duties to improve the health and well-being of others.

JANUARY / FEBRUARY 2021

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WORCESTER MEDICINE

Society Snippets

Student Student--Physician ~ Meet and Greet Sponsored by the WDMS Medical Student Committe

Wachusett Mountain, Princeton MA Saturday, October 17, 2020

W NE

!

WDMS Medical Student Committee Members

Dr. Anne Larkin~Physician Chair Bennett Vogt~Student Chair~MS2 Calvin Schaffer~Student Vice President~MS2 Nayha Chopra-Tandon~MS3 Paramesh Karandikar~MS1 Iha Kaul~MS3 Richard Moschella~MS4 Kenley Preval~MS2/GSBS1 Kurt Schultz~MS4 Michelle Schabo~MS4 Trent Taros~MS3 Cameron Thomson~MS4 Sarah Uhranowsky~MS1

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EXPERTISE. INNOVATION. COMPASSION.

When it comes to heart and vascular care, your patients deserve the best. ADVANCED HEART FAILURE PATIENTS BENEFIT FROM VENTRICULAR ASSIST DEVICE (VAD) PROGRAM

• Improves survival and quality of life for advanced heart failure patients as destination therapy or as a bridge to cardiac transplantation • Certified by the Joint Commission SYMPTOM RELIEF AND FEWER HOSPITAL VISITS FOR MITRAL REGURGITATION PATIENTS

• Transcatheter mitral valve repair using the FDA-approved MitraClip device • Minimally invasive for patients with symptomatic mitral regurgitation due to degenerative mitral valve disease MINIMALLY INVASIVE PERCUTANEOUS TRANSFEMORAL AND TRANSAXILLARY TAVR BETTER FOR PATIENTS

• Transcatheter aortic valve replacement (TAVR) – An alternative to open heart surgery for patients with severe, symptomatic aortic stenosis who are at intermediate- or high-risk for surgery • Only team in New England performing TAVR via completely percutaneous transfemoral or transaxillary access • Majority of patients have moderate sedation

COMPLEX AORTIC ANEURYSM PATIENTS REPAIRED PERCUTANEOUSLY OR WITH SMALL GROIN INCISIONS

• Center for Complex Aortic Disease – Only center in the Northeast to offer two forms of fenestrated and branched endovascular repair of abdominal and thoracoabdominal aneurysms through an FDA-approved clinical trial • More than 350 repairs completed • No treated patients have needed to be converted from minimally invasive repair to open, surgical repair ATRIAL FIBRILLATION PATIENTS NOW HAVE AN ALTERNATIVE TO WARFARIN THERAPY

• A nondrug alternative to blood thinners • The left atrial appendage closure (using the Watchman device) procedure prevents migration of blood clots and reduces stroke risk KEEP YOUR HEART FAILURE PATIENTS OUT OF THE HOSPITAL

• CardioMEMS HF System – First and only FDA-approved device proven to significantly reduce heart failure-related hospital admissions • Uses an implanted wireless sensor and remote monitoring

Referrals: 800-431-5151 UMass Memorial Medical Center 55 Lake Avenue North, Worcester, MA 01655 www.umassmemorial.org/heart