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Jonathan Levine:
Welcome to Think Oral.

Mariya Filipova:
Where we connect the unconnected between oral and physical health.

Jonathan Levine:
I’m your host, Dr. Jonathan Levine.

Mariya Filipova:
And I’m your host, Mariya Filipova.

Jonathan Levine:
Let’s get at it.

Mariya Filipova:
Hello everyone. Welcome to the next exciting episode of Think Oral Health with myself, Mariya Filipova and Dr. Jonathan Levine. We are very pleased today to welcome a special guest who sits in an exciting place in the health care delivery system that has visibility into all the opportunities that, from a clinical and workflow perspectives we could see for integrating care across the medical and dental care teams. We are joined today by the chief medical officer of the Point32Health Plan in Massachusetts. Dr. Claire Levesque is the chief medical Officer for Commercial Products at the Point32Health Plan. Claire, welcome and could you tell us a little bit more about your current role and the purview of the types of patients and beneficiaries you take care of?

Claire Levesque:
Sure. It’s a pleasure to be here. And I represent Point32Health, which is really the coming together of Harvard Pilgrim Health Care and Tufts Health Plan. And so we support members who are receiving their insurance through commercial insurance, Medicare and Medicaid. Right now, I support the commercial membership, but I’ve had experience in all three. So what we really recognize is that it’s important to make sure that we are getting dental care to everybody across the whole spectrum. Now, we’re not the ones who are funding that since we’re not the dental insurance, but we recognize the importance of it because we know that it contributes so significantly to individuals medical health.

Mariya Filipova:
I appreciate also that we have a dentist in the room here, so I’m looking forward to that lively discussion with some very concrete examples. So we keep talking about systemic health and how oral health is part of systemic health. We’ve seen data and statistics, pragmatically in your view, where do you see the opportunities today to for a patient, but also more importantly for practitioners, for physicians and dentists, where they can make a meaningful difference?

Claire Levesque:
Yeah, sure. So certainly when we think about oral health, we think sometimes of course about the restorative care, when people need different teeth taken care of to make sure that they still have good ability to get good nutrition. So certainly that alone is very important and making sure individuals have that capability. I’m a neurologist, so I know that if somebody has, for instance, a stroke and just recovering from that and may not have movement of their mouth, making sure that their teeth are as in good function as possible is really important. So it’s an important factor in making sure people have good nutrition and really feel good about their, their face and their appearance. On top of that, there’s tons of research that shows that just dental cleaning is critically important, that the dental cleaning contributes to better health for individuals with diabetes, makes cardiac disease less likely, all of those sorts of things. So making sure that individuals know that going to the dentist is just as important as coming in for their annual physical or doing the other preventive care that they have.

Mariya Filipova:
Yes. And in that sense, where would it be most effective? Are we expecting, as patients, to go in and really ask our dentists and be more proactive and ask our primary care doctor? Or is there something from the dentists and the PCP side to make it easier for those procedures and services to happen? Because we know everybody knows that there’s a, well, most of us by now recognize the connection, it’s the follow through and what do we do about it?

Claire Levesque:
Yeah, that’s a good point, because I do think that dentistry and medicine have evolved so separately that there’s not great connections. And it would be much better if, in fact, primary care doctors understood the importance of dental care and knew where to refer somebody and vice versa. And more dentists now are asking about medical problems when somebody comes in. But having that communication back and forth between the dentist and the PCP would add another layer of care for the patient.

Mariya Filipova:
We have one of those dentists who is asking their patients about this here with us today. Jonathan, how does it currently work or does it in your practice and what you’re seeing?

Jonathan Levine:
Well, I mean, what I’ve done over the last three decades is look at innovation that can create some breakthroughs for connecting the dots between dentistry and medicine. I mean, clearly, if we look at the systems and Mariya said it very well that the mouth doesn’t know that it’s not connected to the rest of the body. There’s been this separation of dentistry and medicine. I was very fortunate, I went to Boston University Goldman School of Dentistry, and like Harvard, the dental school is basically part of the medical school, not as integrated as Harvard, but pretty well done. We were all together for the first two years MDs, DMDs and PhDs. But the idea is that if you’re learning together and if you’re educating together, if you understand that the jaws and the mouth is one, beginning of the digestive tract, two, is critically important in the ability to breathe. And if you can breathe properly and get into deep sleep, the reparative nature of that we know so much today about sleep. When you start looking at inflammation and inflammation in the body, now there are 58 systemic inflammatory diseases that are connected to inflammation, chronic inflammation in the mouth. When these data points and this research comes out and I applaud what Claire just said because we really need to break down the walls and it’s only through the technology and the technologies that we’re using in our practice and we call it a healthy mouth baseline, but basically it’s an oral wellness score that our patients get that has everything to do with inflammation, airway, PH, all of the component pieces of health of the mouth, which is basically translates to the health of the body. So we believe that oral health is the tip of the spear and directly links to overall health. And if we can come up with technologies that, where we have a record, a health record that connects the dots, that is a great start. If we’re looking at blood pressure and we’re talking to the physicians, fantastic. If we’re looking at HPV virus and getting ahead of oral cancers, which is morbidity rates haven’t changed in 50 years and it’s actually on the rise. These types of things, we can have great benefits to our patients and a lot of it has to do with how these business models can integrate much better and where do we start? So I’ll hit pause, but I’d love to hear Claire’s thinking on that. And what are some of the things that we can do from on the business model side to maybe help connect the dots better?

Claire Levesque:
Yeah, I think that you’re right, that if we can have more ways where it’s easy to share information back and forth, that would be very helpful. As we know, unfortunately, electronic health records has been built in ways that they don’t always communicate, which makes it very difficult. But working on some of those technical issues would be fantastic. And then we also have to sometimes, like with the HPV vaccine, I always say that, I know I’m in suburban Boston where Middle school kids all see the orthodontist, but they don’t always see their pediatrician anymore. We definitely should have those orthodontists, those dentists pushing out the HPV vaccine and talking to the patient and the family about it, and then even giving the HPV vaccine. And everybody pushes back on me and says, well, dentists can’t give vaccines. And that seems pretty absurd to me. If you can figure out how to give somebody anesthesia, one would think that you could give them a vaccine. And so people should be able to get the vaccines wherever they’re coming the most frequently. And if that’s the orthodontist office, let’s do it.

Jonathan Levine:
Yeah, I couldn’t agree more. That’s exactly right.

Mariya Filipova:
There’s, exactly. I mean, there seems to be a bit of a maybe I’ll call it out a tension or two schools of thought here, Jonathan. You’re talking about the need of technology to allow interoperability, right? Sharing of data and information. I do want to make sure that for our listeners, when we talk about technology here in dentistry, this is truly baseline information and technologies that other industries take for granted, right? When you go to Amazon and you want to purchase something, they have history of your prior purchases, or if you go to one store and one retailer and then you want to purchase something in a different store, their systems talk to each other so you could call out what you purchased in the other store. Terrible analogy, but other industries tend to have that baseline of transactional information. In medicine, in healthcare, that, that has advanced, right? So now patients can take their medical records from one system to another. However, dental and medical providers still tend to be in a very different level of technology advancements or different types of providers. And so we’re not talking about quantum computing and advanced AI algorithms. We’re talking about baseline infrastructure that allows interoperability. I mean, how many of our listeners have had good experience of going to a dentist and walking away with their scans or their records? Even, how many of our listeners have actually thought about getting their dental records with them when they change dentists? And that, that’s a bit of a novel thought. So baseline when we talk about we need more technology, it’s nothing, it’s nothing fancy, it’s baseline infrastructure. And secondarily, I tend to believe that the real barriers to collaboration are along the, along the lines of the business models and the ease of integration of the workflow. And maybe let’s take one or maybe even the way we’ve set up the system with the different incentives and associations. So maybe let’s talk about the HPV. Take one specific example. What might we want to see happen differently and where would these barriers to integration be, right? Assuming we have a way to share information, because I don’t think that’s a rate limiting factor, right. Coming up with the infrastructure, what would we need to see happen differently for any of those examples?

Claire Levesque:
Well, it’s interesting because for the vaccine example, many states now have vaccine registries. So I think one of the pushbacks on sometimes a dentist giving a vaccine would be that the pediatrician didn’t know it happened. But if it’s going into a state registry and both the dentist and the physician can see that information, then you remove that barrier. So you’re not concerned that, say, parents will forget what vaccine their child got or whatever might happen and then somebody would, would be would end up with extra vaccine or no vaccine at all just because the information wasn’t correct. So think if we can use that system, that would be great. But it does also mean that more of that connection with when a pediatrician’s in a town know more about the dentists and the orthodontists near them, know who’s there, know who’s serving pediatric patients. Now, HPV is approved to older age range, too. So it still would be very relevant to be discussing this with folks as they get older. But again, the same thing would apply, that it should go in the vaccine registry, which again makes it easier for that communication to happen.

Mariya Filipova:
Jonathan, if you’re a dentist running a clinic, would giving a vaccine to a patient be a good business? I can’t imagine that with the requirements for storage, how much of the product needs to be thrown away if it’s not used? So if you have certain number of chair hours and you’re trying to have a, run a productive practice as a small business, is that a good business if you’re a dentist running a small practice?

Jonathan Levine:
Well, what you say, is it a good business? I think it’s absolutely in the purview of a dental specialist, a general dentist. I’m a prosthodontist. To give an intramuscular injection, I mean, one thing dentistry knows how to do is give an injection, that’s for sure. So I don’t think that’s a problem at all. I also think there’s a diagnostic side of this because now with salivary diagnostics and some of these new testing of salivary diagnostics, the ability to detect HPV virus is very interesting. And once you can baseline and detect, you then can offer up, well, what are we going to do? And because people really need to know, what is that microbiome like, what are those pathogenic bacteria and what are the viruses that are resonant? It could then you can problem-solution and then take action through, let’s say, a vaccine. But I think it’s absolutely in the purview. But it’s I think a lot of this is about sharing information. And if one, one option is to have a health record that is shared, be amazing, or even a patient portal record where the patient owns their data and it’s rolled up from the health care system and to-from private offices. And that would be a great technology breakthrough, and companies that are working on this would allow for the patient to own their data and then the ability to share that with any office they move to. If they went from New York to Boston to Miami and they owned their own data. The biggest problem we have is when health systems have to talk to other health systems or dentistry has to talk to medicine. We seem to get all snafu because of that. So it’s got to be common soon. And I think some new technology and new breakthrough in it and all the new computing, it has to happen soon.

Mariya Filipova:
I love the way you twisted my question and answer the question you wanted to answer, because I think that shows a different way of thinking about this question about delivering an HPV, because it allows, it’s not necessarily of what’s my net revenue per chair hour that I need to compare one procedure versus the other. It’s much more about what is the positioning of the dentist within the overall care team for that patient and how can we better take care of that patient holistically over a period of time that extends beyond that one, one visit? It’s really great demonstration of a completely different mindset of a dental provider today.

Jonathan Levine:
That and that is my mindset because the hygiene room in the dental office is actually the innovation center of that dental practice. It’s really where it all happens because the patient is there very willing, and our new technology from scanning from digital workflow, from all of these new technologies that allow us to see where airway, sleep, microbiome testing, all of these new type of baseline testing is coming to dentistry, it’s around the corner. On the business model side, to your first question, is a great question, is what is the financial side for the dentist? Because there is, of course, there’s motivation there. But my career has always been in a private fee-for-service world, and it’s how do we deliver care at the highest level and then that’ll trickle down to other type of payers where we can, where it will make sense even on the insurance side because we’re getting ahead onto more of a wellness model, not a sickness model. We’re not waiting for something to happen. And I think we all know that mindset is the long view not too short view, but it’s one that it will work for all stakeholders.

Claire Levesque:
I think another important role in dentistry, of course, is education of the patient. And I think when I first, my oldest memories of seeing the dentist, there was no education at all. It was open your mouth and we’re going to do this or that and then we’re done. And I think through the years, I’ve seen more and more focus on at least talking through about how to have good dental hygiene, what things you can do. And there is a real opportunity there for dental hygienist is taking 45 minutes to an hour to clean your teeth. There’s a lot of education that can happen there and certainly I think that’s an important role both for, for physicians and for dentists around how important oral health is.

Mariya Filipova:
I appreciate that point around patient education. And I do want to get a little bit into the nitty gritty of what, what would accelerate the adoption of a certain innovation or an idea, even if it’s delivering better outcomes for patients. I spent my, better part of the last decade of my career as an innovator in different roles in health care. And I think the best way to summarize my role is spending my time buying the short term ROI of long term thinking inevitably results in, in outcomes in health care take longer than a quarter to materialize, yet the investments are typically front-loaded. And so inevitably we need to have this balance of what is the expected ROI and over what period of time. And is that something we can, it’s in line with our strategic vision so clear from a health plan perspective and maybe put your different hats on, right? Because not every, not every health plan in commercial or government setting is, looks at it the same way. How would you evaluate something like, let’s say, an integrated care solution for sleep, right? As we mentioned, as Jonathan alluded to, the way you breathe is connected to your jaw, to your, so a dental professional could be part of your care team for obstructive sleep apnea, and that would fall on the medical side of the insurance, not the dental side of insurance. So how might you evaluate as a health plan the opportunity to pay for that type of treatment?

Claire Levesque:
So I think that’s a great example of how things fall between the two areas. And so what we certainly want is people to get prompt diagnoses of sleep apnea if that’s what they have. And certainly I think both dentists, trained dentists and trained physicians can make a decision that somebody needs a sleep study and may in fact have sleep apnea. And so certainly that’s one path we want, is to get that diagnosis as soon as possible. Another thing, of course, is the treatment path, which can go several ways. So it can certainly go the path of CPAP, the machines that really push air down into the throat and keep the airway open at night. And it can also go the direction of oral appliances. And what we need is to get the treatment that the patient can tolerate and make sure that they’re going to comply with it and hopefully get good results. And so, I think like a lot of things. Not everybody responds to the same kind of treatment and some folks fail CPAP, but sometimes with a different mask, they can do well or sometimes they fail it and nothing seems to work and an oral appliance is better or vice versa. Everybody is unique, so making sure that we can have all of those options open and then making sure that it can be done in at least a reasonably coordinated fashion. Because I think right now that’s not what’s happening. So if somebody goes to, say, a pulmonary doctor or a neurologist or the various specialists who often diagnose sleep apnea, what happens next is that they would get referred for CPAP. But if CPAP fails, I don’t think there’s a good connection to a dentist. And if sometimes somebody wanted to reverse that process, for some reason, that certainly is not very available. So having those abilities to keep everybody coordinated about path and to recognize the other thing that we do in health care is we can be, become such big advocates for the thing that we know best and do that we ignore the other sources of treatment. If you provide oral appliances, you think that’s the best approach. If you do CPAP, you think that’s the best approach and in fact the best approach is the one that’s the best for the patient.

Jonathan Levine:
Yeah.

Mariya Filipova:
Exactly right.

Jonathan Levine:
Yeah. I would ask the question about diagnosis and I would say it to a panel of sleep doctors and sleep dentists, because what’s happening today in the dental office is we have some new technology around, Cat scans, CBCT, and working with pulmonologists, they don’t really, they’re not really taking as deep a dive on some of the things that we look in dentistry and together we’re so much stronger. So from a diagnostic standpoint, if you say that the patient comes to the dental office or they go to their physicians, the diagnosis of early stage sleep disorders before they get to moderate to severe sleep apnea will save insurance companies millions of dollars. And you need to run a test on that only because they won’t get the hypertension. They probably have a better job on obesity. They’re, they’re sleeping better. Getting regenerative deep sleep. If we can solve the issue, and a lot of it has to do with the early stage of sleep disorder and just like early detection cancer, it’s the same thing with sleep, but it’s only going to happen when we work together. So in dentistry we have 4 or 5 very good options, but there’s a diagnosis. What are the jaws like? What’s the size of the jaws? Is there nasal obstruction? Is there an upper airway restriction? On and on with these type, do you breathe through your nose? Do you breathe through your mouth? What’s the palatal tissue like? We call it myelopathy one, two, three, four. On and on. But we look at things from a dental specialty standpoint, and then the physicians or the pulmonologists look at theirs. And when we start coordinating that together and as new technology comes, that may be a platform that puts them together or better sharing of data, they’ll be better outcomes for sure and better options for the patients just to what you just said, Claire.

Claire Levesque:
Yeah, and I think it’s interesting that you also when we look at the ROI, so, you know, certainly with sleep apnea, some of the improvements are not this year, they’re going to be down the road. So not developing hypertension in the future. But the other area where we think a lot about dental care is in diabetes and literally had a discussion this morning about how do we front load more care for folks with diabetes so that down the road they don’t have complications. But that’s not the way companies think often because the ROI is supposed to be this year. So if we improve the care for individuals with sleep apnea or diabetes or whatever it might be this year, their care is going to be more expensive because we’re doing a bunch of stuff. And so it becomes hard to sort of demonstrate that ROI, which is unfortunate, and that’s a constant difficulty for us.

Claire Levesque:
That is the crux of and am taking notes for those of our listeners who are looking at opportunities to innovate and problems to solve, ability to track and attribute value longitudinally to a certain intervention is a game changer is what I would describe it in health care and in dentistry, because as Claire mentioned, front-loading some of those treatments is the right thing to do but they also add up. Over the course of two years for an abstract to treat, diagnose and treat obstructive sleep apnea, it could be upwards of $5,000. And that adds up in addition to all the other conditions that other interventions in that path to treat for a diabetic patient. And so if you’re, and perhaps that’s where we probably need to get a little bit more granular when we talk about insurance, right? So if I’m a self-insured employer and if I have a stronger or if I have a strategy of retaining my employees in a longer period of time and I want them to be productive and I want them to be happy and stay with my company. And I don’t want them to take sick days to go and get a root canal or to come and sleep deprived to the office. That may be somewhere where we could start stitching the dots together for more of a longer term ROI. Do you see opportunities in that market as probably an early adopter or more receptive to some of those frontloaded interventions for a longer term total cost of care that might be lower?

Claire Levesque:
Yeah, I think it’s an interesting question about how do employers view this. And certainly, as you said, employers, is a difficult time for employers where a lot of people are changing jobs, leaving the workforce, whatever it might be. So retention of employees is very important and making sure that benefits are very strong and that benefits are very comprehensive is certainly important. So ensuring that individuals have both medical and dental insurance that covers them very broadly is important. There can be things such as more frequent cleanings for individuals with diabetes, making sure that’s built into the dental insurance that they have, making sure that the dental insurance covers the braces for the kids in a way that’s relatively comprehensive. So I think that employers do respond to that. They do want it to be put in a format that they can push the information out to their employees in a way that’s very understandable because we all get our annual re-enrollment stuff from our companies and half of it is so obscure that we’re not really sure that we got any benefit from it. So the more that it can be put in a fashion that’s very understandable by the employees, the more important I think it can be to them.

Mariya Filipova:
I think that’s part of what we need to think about in, in terms of applying and adopting some of the solutions. How do we make and I know obstructive sleep apnea. So for those of our listeners who may have a loved one or a partner who might be struggling with obstructive sleep apnea or who find themselves sleeping on the couch while their partner is being loud and during the night, please keep that in mind and consider your dentist as part of your overall care team. Talk to your doctor and think about vended options is what I’m hearing here. Because there may be solutions that go beyond the CPAP for which, as we know, compliance rate could be as low as 40%. And that’s some patients are just to, to Claire’s point, may not be the right fit for that solution.

Jonathan Levine:
Let me just interject one thing. Quick thing. I mean, look, I do think that new science and research and the fact, they’re going to set us free a little bit here. There’s a subjective nature on some of this conversation which, which technique is going to work best for which person. But when you’re investing initially for a long term result, it seems to me that some good scientific studies and I’m sure there are some baseline ones now will be very helpful because, well, what happens with intervention? What happens when we’ve controlled some of these sleep disorders and what happens to their if they had a baseline of cardiovascular disease, inflammatory markers, all the things that we could look at. And we would ask Claire, how do the insurance companies and the health systems, how do they look at that thinking what, how can policies and protocols change in relationship to new science and new research just similar to what’s emerging from sleep and all the science around that?

Claire Levesque:
Yeah, So certainly we do have we have our medical technology team that reviews the different things that are coming out. And sometimes it can be hard because the information can be very sparse. And of course the information is the most sparse in the areas of the long-term follow-up. So we look at things, we use external companies that also can review things and pull the research together for us because there’s always, there’s technology in so many different areas and we can’t be expert in all of it. And then we look at, is the data there to say it’s something we should be covering? We also, of course, being a company that’s Medicare, Medicaid and commercial, so at times we are bound to just follow what CMS says. So on certain things, if CMS says we need to cover it for Medicare, then we do. If CMS says we can’t cover it for Medicare, then we don’t. That’s the reality that that some of those things are certainly also controlled by the government agencies that control Medicare and also Medicaid. But it is a difficult area because of course, often the information in the beginning is very preliminary.

Claire Levesque:
But I do think as more studies are done and as more studies are more, more comprehensive in their nature, that helps us. The other thing that we’re very focused on right now is also health equity. And so one of the problems we sometimes have is studies are only done in, say, white males, people who are males because they’re not going to get pregnant. And then that makes it harder for us to understand if this is something that really will benefit all of our population. So I would encourage anybody who’s on the call listening and thinking about innovating, please try to get a pretty broad spectrum of the population included in your studies because we really need that information. If people of color are not going to respond to the treatment, we all need to know or if they are going to respond perhaps in a fashion that’s even more robust than white individuals. We also need to know that. But to exclude those individuals creates problems for us.

Jonathan Levine:
Mariya, it really goes to the point also of adoption of new technologies, and we like to talk about that a lot. And Claire, to what you were just saying, to pose a question, if you thought about a new technology and bringing it into a health care system, what are those pain points with new breakthrough technologies that you’re seeing and how could we look to change those?

Claire Levesque:
Yeah, it’s interesting question because what we find with the breakthrough technologies is often there’s an early adopter in a particular geography who takes it on and who is usually such a strong advocate that sometimes it’s hard for us to view what they’re saying objectively. And this is the nature of things. And so then we look for a broader spectrum of individuals to give us some information on that. So it may be a specialist who does not offer the service, but it will at least can look at it objectively and give us some intelligent comment on whether this is beneficial or not. But it’s always difficult. And of course, the other thing that becomes hard is things come out and there’s no fee, there’s no billing code. The practical issues are often very difficult. So even how do you benchmark it and say this new technology, is it similar enough to the old technology? That you take the old technology is the baseline fee and add something on to it? Or is it so different that the baseline fee is not actually applicable? So that becomes its own issue too.

Jonathan Levine:
So let me pose something specific. So if we said there’s new research that came out that a leader and a half of saliva goes through the GI system, and now we know because we didn’t think this happened, that one third of the microorganisms seed the gut, that the mouth seeds the gut. And what they’ve shown is that P gingivalis and these pathogenic bacteria seed the gut and in fact enhance any inflammatory gut issues that known as leaky gut, that separation of these interstitial cells and these bacterial byproducts and these pathogens get into these other systems like the gut brain axis that came out of Mayo Clinic about 4 or 5 years ago, and all the science that’s emerging of how our systems are all connected. So if we believe that and we came out with a technology that very inexpensively, we could test our patient’s microbiome in a hygiene room and understand the bacterial profile. How would that be viewed? And of course, I am the furthest thing from understanding insurance than any human being on the planet. But I’m just curious, how does that get viewed? If we could come up with real data, actionable data that shows an improvement of a person’s health once they controlled inflammation and chronic inflammation in the mouth?

Claire Levesque:
Yeah, so that’s a good question. Diagnostic tests, how do we view those? And so I’d say with the diagnostic tests, we want to know that in at least a good portion of folks who have, say, abnormal results, that there’s a clear treatment that would result from that. So one of the things that has been a struggle for us is diagnostic tests where, well, this has happened in the genetic area, where a lot of things are identified, but we don’t know what they mean and they don’t know what they are. And no change happens to the care of the patient. Well, for the insurance company, it’s hard to justify paying things because we, as clinicians, are curious about it. We want to know what’s causing it. And those things we would say should be paid through research protocols. But if you’re saying you’re going to identify things in the microbiome, in half the cases, you may be finding things that then would change something about the treatment, whether that’s diet, I’m totally making this up because I don’t know what would happen, but diet, oral hygiene, mouthwashes or whatever it is, then it starts to become more meaningful to us that we would actually want to cover it.

Jonathan Levine:
Right.

Mariya Filipova:
So it needs to be actionable treatment and.

Claire Levesque:
Correct.

Mariya Filipova:
Change the course of treatment or inform the course of treatment for that patient.

Claire Levesque:
Absolutely.

Mariya Filipova:
I love, I love this example because very recently we were looking into diagnosing early oral cancer. As we know, that’s still a highly prevalent disease. Typically it’s very, it’s discovered in the late stages and chances of survival of, from oral cancer when it’s late stage is in the 20 to 40%. And survival is, quality of life is really poor even if survival is there. However the odds are flipped as some of our listeners know, if the oral cancer is identified early. And so the question is how could we use liquid biopsy, which is just a testing to identify those biomarkers that would result in lesions in the mouth and in the neck area. And the science and the technology is there, right? Researchers out of University of Chicago have identified that highly sensitive and specific test. Now the question is, what do we do with it? And it’s, I love this example because it’s another great opportunity for medical and dental collaboration where diagnosing oral cancers and the screening for oral cancers happens in the dental office when all of us go to for our annual dental screening and cleaning, our dentist would move our tongue around and see visibly inspect if there are any visible lesions.

Mariya Filipova:
And if they do see something, they’ll send us for a biopsy or they’ll observe us and then a couple of months. Now, here, in this scenario where we have the equivalent of a Covid test where you give a saliva sample and then it comes back with a certain level of sensitivity and specificity that you might actually have early lesions that might not even be visible, right? What do we do then? Right? Most of the treatment actually happens on the medical side and it’s in the hundreds and millions of dollars in terms of how expensive and invasive it is. And so in that situation, which is very real, I do. And I am, I kind of welcome, kind of your thoughts and ideas on what might be a path? And is this one of those opportunities where we could see a great where the stakes are so high, right, the cost and the quality of care, the improvement could be so dramatic that warrants the collaboration on the dental and the medical side from purely a insurance and business model perspective.

Claire Levesque:
Yeah. So when we’re talking about screening tests for cancer, one of the things that all of the insurance companies follow is the US Preventive Services Task Force, I think I’m getting the name right, we always look at what do they say? And what will happen is, for instance, they recently changed the screening age for colon cancer. They lowered it from 50, age 50 to 45. So if you have sort of an oral cancer screening test and that task force reviews it and says totally making this up, at age 40 this should be done annually, or the evidence shows that if somebody smokes, it should start even earlier or whatever it might be, then I think that’s something that becomes more acceptable to insurance companies because there’s a clear guideline. And then all of the dentists would also know that if they’re screening somebody who’s 25, they need to have an extra reason like that person had a very strong family history of cancer or something like that. But that in general, for most individuals it would start at a later age. So think that would significantly help that sort of, those sort of practices. Be well accepted. It also is good to get in that sort of literature that’s usually used by the physicians. It’s listed there. It starts to become something that doctors pay more attention to and something that they may refer their patients to the dentist and say, you know what, you’re now 50. You need to get screened for oral cancer or whatever it might be. And this is where I’m making up all of the statistics because I don’t know any of them. But the fact that there would then be clear guidance and the guidance would apply to the dentist who was doing the procedure, but it would also be very visible to the physicians who were referring for the screening.

Mariya Filipova:
Yeah, the logical decision tree will be there. Very helpful.

Claire Levesque:
Right.

Mariya Filipova:
Jonathan, what do you think?

Jonathan Levine:
I think that’s exactly right. The more the physicians are educated and of course, the dentists are educated too, on the medical side with what their knowledge is, the more they’re going to be proactive to create this communication. Here’s a great statistics, people with periodontal disease are three and a half times more likely to end up on a ventilator. Well, how did that happen? Well, you got a cytokine storm and you got your body is on high alert for inflammation because of chronic periodontal disease, just like any other inflammatory disease in the body. So the more studies come out, the more the data is there, it builds wonderful rationale of why everybody needs to be collaborating and clearly working together. I mean, from, there’s 20 years of studies of this now, Moisi Devereaux studies and the best studies 20 years ago, connecting the dots between gingival sitting in the media of the carotid artery of cardiovascular disease. Well, what’s P gingivalis doing in the carotid artery? It’s a pathogen of the mouth. It’s there now, isolating it in colon cancer, pancreatic cancer. I mean, it’s a long, it’s a long list. So if I’m a physician, I say, well, I’m going to check the mouth and I see some inflammation. I want to send you to my dental. And that’s not a business model partner, but my health care professional. And I look at dentists as oral physicians. That’s what dentistry is. It’s just that we have this word called dentists, and everybody thinks of Little Shop of Horrors and, and Marathon Man. But it really is part of this whole health care team. And I think the more we know and the more we learn and work together with all the stakeholders, the more we’re going to be able to have better outcomes for our patients and get to the, those early diagnostics at a much, much better time.

Claire Levesque:
Well, the other thing too, is that as a neurologist, I always had to pay attention to the seizure medications that caused gum overgrowth. And so there’s definitely medications that also impact the mouth that the physicians should know about and should be making sure that they’re referring individuals to the dentist.

Jonathan Levine:
Yeah, exactly. Yeah. Yeah. Dilantin caused hyperplasia.

Claire Levesque:
Dilantin, Yes.

Jonathan Levine:
Yeah, that’s right. Latest research of one of the other systemic inflammatory diseases, Alzheimer’s disease. So Andrew Kramer’s group at NYU connected the dots with P gingivalis and Alzheimer’s. And what’s the pathway? Is it directly from the cardiovascular system of we call it leaky gums, like leaky gut? And I’m finishing up a book on oral systemic medicine. I’ve been looking at the latest research and it is incredible the research that’s coming out that really is connecting our systems. So I, and I would ask you, Claire, is like, as you think forward a little bit as this new data comes through, as the physicians are more aware of it, as the medical students and the dental students might be connected a little bit better and they’re being educated at their early years. Can you see a transformation in health care where the, the transdisciplinary, if I can call it that, or the cross-pollination between dentistry and medicine can really happen?

Claire Levesque:
Yeah, I do think it can. And it’s going to take people putting a very specific focus on it. We can’t just think that passively. We can put a little information out there and everybody’s going to look at it, but rather we have to make sure that we’re pushing the information out in different ways. And I do think that one of the things we have to look at, just like when I’m trying to do an education about vaccines, including HPV, every part of the health care system has to be taking this on. We’ve talked a little bit about the providers and about the role of the health insurance, but what’s the roles of, say, for instance, the Department of Public Health and the States and all these other entities that could also push out this information and make sure that we’re thinking about oral health and medical health in a more comprehensive fashion.

Jonathan Levine:
Yeah, excellent.

Mariya Filipova:
I hope the patients in our audience are taking away the not necessarily the complexity and the overwhelming connectivity of our integrated health and our systemic health, but they’re taking away the wealth of resources that are available and hopefully the empowered mindset of actually asking the question. And not every dentist or physician, unfortunately at this stage will have the time or the mindset to engage in that conversation. But increasingly there are many more providers who are welcoming those questions and those conversations around connections. I do want to end on a positive note, especially as we were talking about how long it takes to generate clinical data or how long it takes to put something into guidelines and then for it to become policy and insurance. First of all, it is doable. It has happened and it dynamically, in every health plan or a system, there is dynamically and periodically reviewed of what the policies are and what needs to be adapted and changed. So this is not a once-in-a-year annual process that happens, and if you miss it, you’re out of luck. It’s truly a matter of engaging in a conversation with key decision makers and stakeholders and experts like Claire Levesque today, who will guide the entrepreneurial teams and the technology teams on what is the right pathway. I guess my takeaway here is there’s a process, you can’t cut corners, you have to go through the process, but it is doable. And with the right mindset, there is a positive intent to actually be able to do something and change the process in the system. Claire, I hope I’m not putting words in your mouth, but this is the positive person’s interpretation of what you just described for us. If there’s somebody who has a glass of half empty mindset, maybe they would have heard a different story. But that’s what I heard when I heard you describe the process.

Claire Levesque:
I think that’s great. That’s a great summary about how we all have to think positively so we can all take on our own role in moving this in the right direction.

Jonathan Levine:
I would add, Mariya, I really believe that there’s a consumer conversation here. There’s a, the patient-person conversation. And the more they get educated and we could go back to sleep and think about James Nestor’s book on Breath and Mary Otto’s book on Teeth, describing the inequality of oral care and oral health in America. That type of information, when it gets out to the public, there’s a nice, gentle nudge into the health care system as people go to their physicians or their dentists and ask them questions, and all of a sudden that, that health care person is going to say to themselves, I really got to start learning these things or this is really interesting. And so there is this kind of this nice bottom up pressure I think that can happen through this type of information and education getting out there to the public.

Mariya Filipova:
Maybe in closing, we are at the beginning of the year in this episode. What would we like to see happen in that in this field in 2023? We could be you could be as ambitious or as tactical as you would like. But what would you like to raise a toast at the end of 2023? When it comes to dental medical integration, what would we want to celebrate?

Claire Levesque:
I would love to celebrate doing better in the prevention of oral cancer, the HPV vaccine, the diagnosis of early oral cancers earlier.

Mariya Filipova:
Jonathan, what’s on your?

Jonathan Levine:
I go along with that. I would add to this diagnostic group of oral cancer detection is about 15 to 17% of all dental offices actually do some of this early detection because there are a couple different techniques that we do have in dentistry. So I would love to see that number go sky high. And these diagnostic techniques like around microbiome and understanding our airway in dentistry, that there is a greater collaboration there and our diagnostics and how we deliver that by the end of the year that we somehow see positive movement in that direction. And I think a lot of that’s going to come down onto the payer model and the business model of making that really happen.

Mariya Filipova:
I echo what you’re saying, but maybe I’ll just plant a different seed here. On the flip side of this, I’d like to see primary care physicians talk about oral health inflammation. And actually, as of this year, we will have a CPT code that physicians, primary care physicians, could use to bill for applying silver, diamond fluoride or pediatricians for pediatric patients. And so talk about coming full circle to Claire’s point about sometimes you really just need a billing code, right? It starts with as that simple and tactical. And so what I’d like to see more kids get in STF in the primary care office once the code is approved and ready to go. All right. On that happy thought. Thank you again, Claire, for joining us. Thank you for listening to all of us and see you next time.

Claire Levesque:
Thank you.

Jonathan Levine:
Thanks for listening to the Think Oral podcast.

Mariya Filipova:
For the show notes and resources from today’s podcast,

Jonathan Levine:
Visit us at www.OutcomesRocket.Health/ThinkOral.

Mariya Filipova:
Or start a conversation with us on social media.

Jonathan Levine:
Until then, keep smiling.

Mariya Filipova:
And connecting care.

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