SMILE Health: Integrating Oral Health Into Overall Health

Steven Collens, MATTER CEO (00:13):

Hello, and welcome to today's event, integrating Oral Health into Overall Health. I am Steven Collens, the CEO of MATTER. We are a healthcare technology incubator and innovation hub. Built on a belief that collaboration between entrepreneurs and industry leaders is the best way to develop healthcare solutions. Our mission is to accelerate the pace of change of healthcare, and we do three things in service of our mission. First, we incubate startups. Since we launched eight years ago, we've worked with more than 800 companies that range from very early to growth stage startups, and we have a suite of services to help them At every stage of development. Our member companies have raised 5 billion to fuel their growth. Second, we work with large organizations, health systems, life sciences companies, payers to strengthen their innovation capacity. We help them find value in emerging technology solutions, unlock the full potential of their internal innovators, and create more human-centered healthcare experiences through system level collaborations.

(01:24):

And third, we're a nexus for people who are passionate about healthcare innovation. We bring people together to be inspired and learn and connect with each other. And we produce a lot of programs, including large scale events for the broader community, as well as small forums that are exclusively for our members. This is our second year working with CareQuest Innovation Partners on SMILE Health, which is a first of its kind program that advances technologies to improve oral healthcare. In 2022, we released a call to action to entrepreneurs to develop solutions to make oral healthcare more accessible, equitable, and integrated into overall health. We received submissions from around the globe and ultimately worked with five incredible startups, OraQ, OrisDX, Sleep Architects, Snowcap Crowns, and Wide Awake VR. These companies received mentorship curriculum, and most importantly, validation studies with industry leaders such as Colgate, Cigna, Delta Dental, and 42 North.

(02:29):

You will hear in a few minutes from Dr. Rifat Hasina, from OrisDX, about the experience of participating in last year's program. We launched the 2023 Smile Health Program in March with the same focus on making oral healthcare more accessible, equitable, and integrated into overall healthcare. There has, again, been interest from around the world, and I know many in the audience today are entrepreneurs who have come to learn more. And if you're from an established company or you're an investor and are wondering about ways to get involved in SMILE Health, there are lots of ways to do so, and you'll hear a mo more later in the program about how you can get involved, too. To kick things off, I wanna introduce our first two speakers. Mariya Filipova is the Chief Innovation Officer at CareQuest Innovation Partners. She oversees innovation, incubation, and investment activities to develop solutions that advance oral health, access, equity, and integration for underserved populations. She was previously at Anthem where she led efforts to accelerate Anthem's transformation to a digital first enterprise. Thanks so much, Mariya, for your partnership for being part of this program today.

Mariya Filipova, CareQuest Innovation Partners (03:39):

Great to be here. Steven.

Steven Collens, MATTER CEO (03:41):

Dr. William Giannobile is school, is the Dean of the Harvard School of Dental Medicine. Dr. Giannobile is a leader in the field of periodontology and an internationally recognized scholar and oral regenerative medicine, tissue engineering, and precision medicine. His research focuses on oral and periodontal regenerative medicine, tissue engineering, and precision medicine. Thank you so much, Dr. Giannobile, for joining us today.

Dr. William Giannobile, Harvard Dental School Dean (04:11):

Thank you so much, Steven. Glad to be here to join Dr. Mariya Filipova as well.

Steven Collens, MATTER CEO (04:18):

Now I will turn things over to you, Mariya.

Mariya Filipova, CareQuest Innovation Partners (04:22):

Thank you, Steven, and good morning everyone. I am so pleased to be in this conversation again in joining this community for second year with our small health 2023 program. This is such a joy and a pleasure to be able to kick off the program and also highlight the last week of applications. So all of you who are procrastinators like myself, who like to wait until the last minute to get that extra in inspiration to complete your application, please do so, and hopefully today's conversation will answer some questions and clarify the mission of the program and the impact that we're looking to drive. I couldn't be happier to start the conversation about oral systemic health and the opportunities in oral systemic health with Dr. William Jank. He is, as Steven mentioned, he is the 11th and newest dean at the Harvard School of Dental Medicine.

(05:30):

And Dean Albi, I'm so happy that you're here with us today. So congratulations and welcome to the conversation. I, I would like to perhaps kick off with a question that's in the back of the mind of many of our listeners today. And many of the entrepreneurs, and frankly even the investors that we speak with at Care Quest Innovation Partners, we are focused on making oral health more accessible, equitable, and integrated for all. And when I think about those three characteristics, access, equity, and integration of oral and medical care many you know non insiders to oral health question, whether there are truly opportunities in oral health team to engage. And so if I asked you where do you see currently the pain points or the gaps in our oral health system where innovation and entrepreneurship could make the largest impact what would be those top three things that come to mind for you?

Dr. William Giannobile, Harvard Dental School Dean (06:40):

So, yeah, thank you so much, Mariya, for the question, and again, the opportunity to be with you today. I think it is an exciting time in oral health research and as you know, the topic of this webinar today on integration of oral health and systemic health, and how can we kind of crack through those many barriers that have existed between medicine and dentistry? You know, it, it stems from a long history of our medical and dental schools being separated, and many people who are seeking out oral healthcare feel that they have to navigate a very separate system from the medical system and, and gaining access to the care that they need. And so this whole access issue has become a challenge, especially for many of those underserved populations where there are limitations in the payer systems that are available for these individuals. So we look at the reach and the, you know, the bolus of practitioners in metropolitan areas, but we see so many different oral health disparities that exist across the country.

(07:51):

And that has led to many different challenges in the clinical care models. So one of the things that, you know, at the Harvard School of Dental Medicine, we have this integration with our school of medicine where we have sought for many decades to work to provide this integration. And so many know that within dentistry, there tends to be more of a surgical model of clinical care. So many people go to the dentist to get restorative reconstructive care. They may be in pain, and so they seek out that care for those urgent needs. Oftentimes, they may be reconstructive or there, there may be a problem where a tooth needs to be removed. A root canal therapy needs to be performed, a filling needs to be done. Whereas on the medical model of care there hasn't been as much of an emphasis.

(08:51):

I think those of us in dental education recognize that. But trying to create more of this emphasis on prevention and access to those, those populations in terms of education and public health, and so much got exposed during the pandemic in terms of inequities across the country. And oftentimes, you know, even the World Health Organization said, it's not critical to see your dentist at this time. Let's focus on those most medically necessary procedures. Well, there is now such a backlog and that, that you know, that that difficulty ends up there. Yes. And then you're, you know, if as you're mentioning the three different points and how that relates to entrepreneurs and those involved in innovation, I think that there are great opportunities in terms of innovation on both the reconstructive side, and we can talk more about that later. But also on the preventive side. And I know the second part of this webinar, you're gonna hear about an oral cancer diagnostic, and how can dentistry better engage diagnostics using digital technologies to better diagnose and prognosticate disease through personalized precision medicine types of mm-hmm. <Affirmative> opportunities.

Mariya Filipova, CareQuest Innovation Partners (10:15):

Yes. That's that's such an important point to highlight the, the need for preventative care interventions rather than restorative care. The, the, this notion that unless something is hurt, is hurt, is hurting or painful, you don't really go to the dentist. And that that ultimately adds up to something much more serious down the road. I, I want to make sure that you address some of the questions around, you teed up some of the issues around access and equity. And many of us think about access and equity when it comes to, you know, ethnicity. And it is true that black adults are over 60% more likely to have an unmet dental need, and Latinos are more likely to report having difficulty doing their job due to poor oral health up to 50% higher. However, that discrepancy between access of care also holds true when it comes to soc social economic status. And we know that people living in poverty are over a hundred percent more likely to have difficulty doing their job because of oral health conditions. And so I do want to offer that to, to our listeners today, to think about equitable access to care that spans beyond ethnicity, but looks at zip code and other barriers to access beyond the, what I would call the top of mind obvious ones.

Dr. William Giannobile, Harvard Dental School Dean (11:41):

Right? Yeah, I, I think, Mariya, you're hitting on a, a critically important issue, you know, mentioning zip code or looking at our black and brown communities where they don't have the same type of access as many other individuals. One of the things as an oral health educator that we've worked to engage on is to diversify the workforce as well. Because the number of black Latinx dentists that we have across the country does not represent our population. And so this is something that within dental medicine, looking at bringing on board healthcare providers and dentistry, dental hygiene, they're thinking of creative models. I know it's a politically charged topic with mid-level providers or advanced dental hygienists mm-hmm. <Affirmative>, but to create different workforce models to engage the various communities that are in greatest need. Just last Friday, there was a, an editorial and JAMA network by the office of the director of the N I D C are on transforming clinical research to meet healthcare challenges.

(12:55):

And the number one leading topic on that editorial, Larry Teak, who's a, a dentist, and the deputy director of the NIH they had leading as centering opportunities around people and equity. That was a number one. That was on Friday that came out. And so it's not only looking at the healthcare providers for these patient populations for research mm-hmm. But also looking at creating clinical trial networks and patient populations that reflect differences in ethnicity, gender, sex, others. And we, we saw that during the pandemic, those individuals that in, in the black and brown communities, they had a much worse morbidity in response to covid infection, for example. And it was based on a variety of factors. Some genetic, some might have been due to the locations. Yeah. And so I think that this ends up becoming very critical as we look at our workforce models.

Mariya Filipova, CareQuest Innovation Partners (14:05):

That's right. It's equity does not only pertain to access, but also has impact on clinical outcomes because we see they vary based on different ethnicities and zip codes and lifestyle situations. And so we, we can't, we can't under we, we can't put enough empathy on that emphasis on that point. Is there you mentioned a couple of time and you at times, and you and I those, those of us who have talked to either of us on the, on the webinar today, no. That we often talk about oral health as being part of overall health as an indicator of poor oral health as an indicator of poor health somewhere else in the body. And maybe it's worth the moment to unpack the ties between oral health and overall health. You are, when we talk about these types of connections, we are referring to a whole host of inflammatory diseases such as obesity, diabetes, pneumonia, even cognitive decline. Your periodontist periodontal disease has recently been linked to increased likelihood of developing dementia or Alzheimer's disease. Could you perhaps step us through some of those most important connections between oral health and overall health and focus on the ones that are most, quote unquote actionable. Right. Things that we could absolutely do something today as patients, as parts of the care team, dentist, hygienist, primary care physicians, and nurses. What are those clinical connections that are most actionable in your mind?

Dr. William Giannobile, Harvard Dental School Dean (15:43):

Yeah. So I, the, these are some excellent points, Mariya. I do think that if we take, you know, so from my own bias as a periodontist, looking at those opportunities, you gave the example of diabetes, metabolic syndrome, obesity, a variety of diseases that are associated with systemic inflammation. So we can work with other healthcare specialists generalists, primary care physicians on bringing together, studying and treating our patient populations in this reciprocal manner. If we consider diabetes in many of the different outcomes related to systemic inflammation, we know that those patients who receive periodontal treatment, this is a microbial infection that occurs. It starts on microbial biofilms on the tooth root surface that then work their way down the tooth and then can lead to local and then associated with systemic inflammation. And so when you have healthcare providers, diabetologists or other specialists within medicine that are focused on diabetic health, cardio cardiologists as well, we have had workshops in symposia with our cardiologists as friends as well, where you do look at when a patient gets a workup to examine their dental health.

(17:10):

And so I think the payer systems that provide the care, they can recognize that you can reduce HbA1c levels and some of the other comorbidities associated with diabetes. There has been a lot of new information on the whole microbiome. We're, we're looking at the microbiome within the oral cavity, but also in the gut microbiome. And it's not only a transiting of those pathogens that are swallowed by the patient when they're being produced within the oral cavity, but also they're eliciting local and distant immunological reactions that affect the gut microbiome. And so we've seen those patients with inflammatory bowel diseases, Crohn's and others. They're associated with this whole connection between the oral gut microbiome and you know, one other group of specialists that we have worked on our own research collaborating with our bone health specialists as you, as you look at postmenopausal women at risk for osteoporosis at increased risk for tooth loss, earlier tooth loss, and collaborating with bone health specialists on systemic therapies that may help with either tooth preservation or in those patients who are at risk for having that decreased bone mass and receiving tooth replacement dental implants, and how we can really work together.

(18:46):

And so there needs to be, you know, this I, I think a stronger integration from that standpoint. But with, you know, the group here, you know, in terms of entrepreneurs certainly these diagnostics offer an entryway for the specialists both in medicine and in dentistry to link together because the, you know, those communication pathways are not as strong as they should be.

Mariya Filipova, CareQuest Innovation Partners (19:14):

Yes. And it's sometimes, all it comes down to is communication and care coordination. And Cummings, having spent decades in healthcare before I joined the oral health movement, and being in oral health, I, I know firsthand how much effort and resources is spent on case management and care coordination. On the medical side, I don't think we're seeing as much effort on that medical, dental coordination. I personally think that that's a ripe opportunity for innovation, not in the sense of shining new TE toys or AI blockchain. We just need somebody to connect the dots for patients, dentists, medical teams, to be able to action some of those insights. I do I'll just give a very quick example. There was a study in Jada published where they looked at cost of care, total cost of care for diabetic patients from 2017 to 2018. And what they studied was for those patients who got their diabetic patients, who got their periodontal disease treated, so diabetic patients who don't have a, their period periodontal disease treated versus those who did, that's what they compared.

(20:27):

And treating periodontal disease purely in this case, meant encourage your patient to max out, use up all their benefits in their current dental plan, did not include cover more procedures or do anything different. Purely make sure that you are going to the dentist and if it's applicable, take advantage of those periodontal treat of cleanings and anything else that's covered by your plan. And what that study found out is that for commercial insured, insured patients, the cost of treating diabetic patients dropped down by 12%. And for Medicaid patients, the cost for treating those patients dropped down by 14%. So we're seeing that in a very, in a, in a in, in the claims data. I encourage, again, those entrepreneurs and innovators to help us care coordinate. And in this case, all we wanted to do was make sure that the patients actually take advantage of the benefits that already exist. That alone would make a big difference in cost of care, care for diabetes.

Dr. William Giannobile, Harvard Dental School Dean (21:34):

Yes. I mean, I think that's an excellent example, Mariya, in terms of looking at something as, as simple, but a large healthcare burden of diabetes. And if we can get this bringing together of medical insurance and dental insurance to demonstrate that, that reciprocal interaction where there can be a true benefit from both sides, as for patients minimally to take advantage of those healthcare benefits, but also to look at some creative strategies for the medical insurance networks to recognize that their patients will be much better served over the long term as it relates to a variety of different healthcare outcomes, including cardiovascular disease. Again, these are diseases that are chronic in nature that often take years and decades to develop. So those, those organizations that have the long view will, will be at a, at an advantage. So, you know, an example that I will give you that we're starting to see in healthcare.

(22:38):

So in medicine and in cancer treatment, there is a staging and grading of disease, so disease severity, and then the grading factors of those co-factors that can affect the disease outcomes. So we'll hear a little bit later about oral cancer diagnostics. We do know that systemic inflammation may be a co-factor, or we may know with arthritic diseases with inflammatory bowel, others, they may be modulated and in the grading of diseases, periodontal diseases, one where smoking in diabetes, two environmental factors can change healthcare outcomes. And we've also seen genetics. And so one study we did about a decade ago on patient stratification looked at patients who saw a dentist regularly, either once or twice a year, and then looked at smoking diabetes in the presence of a genetic factor. And we found those individuals that had increasing risk factors lost more teeth and more expensive outcomes, and in terms of needing to see the dentist. So I think the insurance industry and having these big databases are so valuable for us as researchers in the area, but health policy individuals who can really bring this forward to, to make these policy changes.

Mariya Filipova, CareQuest Innovation Partners (24:07):

That's that's so insightful and, and really what it comes down to, the biggest breakthroughs and the impact might not necessarily come in from the most complicated technology or most complicated solution. Hopefully that message is resonating and coming across clear from both of us today on the call. I, I want to acknowledge a couple of questions that are coming in and requests. Please know that all the studies that we are coding and mentioning, we will provide links for them as a reference in the replay option. I see a lot of folks commenting on the systemic health connections. Yes. During covid there was a severe exacerbation of the need for oral health frankly catching up to bring back our oral health to baseline, if you will. And we do know there are studies to some one of our comments on the, in the chat, there are studies that patients who have untreated periodontal disease or cavities are more likely to end up on the ventilator, are more likely to have an adverse covid outcome.

(25:18):

 And so we have seen that connection as well. I'd love to kind of continue the talk around the conversation around the dental team being integral part of the overall health team, we need to have a much more expanded view of what a health team looks like to take care of the whole patient. And that health team would include the medical team with d with nurses and, and primary care specialists, primary care doctors and specialists. But it would also include the hygienist and the dentist and the nurse practitioner, and the, maybe the school and the community. And so in that context Dr. Oli, we have Harvard is, is in fact the only school in the country that I'm aware of that currently offers an integrated program that looks both at dental medicine and, and general medicine. And there's numerous initiatives on the way really focusing on integrating oral health and medicine from the, from by, from, you know, the very beginning when we educate the future leaders of those industries. So tell us more, a little bit more about why is this a focus for your school and the curriculum that you put in front of the future dentists?

Dr. William Giannobile, Harvard Dental School Dean (26:36):

Yeah. So, you know, the, the Harvard School of Dental Medicine's had a long history of integrating medicine and dentistry. So the school started in 1867, but in 1899, we became a part of the faculty of medicine. And so that has continued to this day. So our dental students train alongside our, our medical students for the first 14 to 16 months. And so they really get this strong basis of their training within medicine anchored. And so there's always been this strong ethos within Harvard that there's the importance of the integration. And I think as we look to the future of dentistry, it's only going to become more important as, as dentistry maintains its status as a healthcare profession. I think this is important because we do see that there are obviously the aesthetic, cosmetic functional concerns of d you know, oral health, dental medicine.

(27:39):

But, you know, having that linkage, I think has been important for our students as they go on to become leaders in either oral health research, education, and in planning of, you know, other dental schools. We've, we've seen that there's been a proliferation of new dental schools across the country, some of them proprietary some of them, you know, not for profit like our school. And I think it's going to be important for the future of the healthcare profession that we're training individuals who understand this integration. And hopefully we can break through to, to have some advances in clinical care where there is more of an integration. So we have felt it's important, and I'm, when you see today, many of the other dental schools don't have necessarily the access to a strong hospital network or other medical colleagues for the collaboration. The dental programs themselves are very solid, but, you know, having that opportunity. And so that's, that's been one of our niches that we've worked to develop over the years.

Mariya Filipova, CareQuest Innovation Partners (28:46):

How do you see that connection in having that integrated curriculum play out in the practice of dentistry? And, and, and I, I have to remind those, those of of our listeners on the phone that about 140 million Americans visit a single healthcare provider, medical or dental every year, but not both. And so if we think that over a third of Americans only see, see either their dentist or their PCP, we truly have only one chance to engage that patient in their overall health. And so to me, that's why this question around integrated care is so important. So tell us a little bit about Dean Giannobile, about how, you know, that integrated curriculum sets the stage for integrated practice care down the road, and what are perhaps as a secondary point, what are the, perhaps the things that a dentist a graduate from your program could do within their scope of decisions versus things that are outside of their, of their relevant influence, things around billing and reimbursement and scope of practice, what's in their, in their sphere of influence and changing and what's out of their ha their hands, if you will?

Dr. William Giannobile, Harvard Dental School Dean (30:07):

Yes. you know, in terms of these questions, you know, looking at these opportunities for interprofessional education, I think is what you're getting at, right? And we see many dental schools are working to create these, these opportunities for students to work together with nurse practitioners, dental hygienists, social workers, other healthcare providers to work as a team. And so that's something that we've worked to create an affiliation we have with the Massachusetts College of pharmacy and Health Sciences. They have a dental hygiene program looking to bring in other healthcare providers you're aware of with a collaboration with the, with CareQuest Institute for Oral Health on looking at the medical billing component, right? Again, we can't ask our healthcare providers to give these procedures, you know, gratis, but to create an opportunity. I, I had seen some of the latest numbers we're approaching 30 million Americans see their dentist or dental hygienists regularly, but do not see their physician.

(31:15):

So this demonstration project that we have in collaboration with CareQuest is looking at trying to develop a, a billing model for wellness visits within the dental practice, and creating a lower stakes environment for many of the patients who have their own anxieties about going in and making that appointment if they don't have an emergency but they can go see a nurse practitioner within the dental office. It's the, it's the flip side. When we see dental patients going to the emergency room for an emergency extraction or a pitis a problem with their tooth, we want to mitigate those types of, of situations. And so, you know, the, the second half of your question, you know, what can we do as entrepreneurs and other healthcare innovators is, you know, are we able to develop models that truly are the win-win where we can integrate within dental offices?

(32:17):

And you've seen with oral maxillofacial surgeons bring on board anesthetists and nurses and other healthcare providers or hospital-based dentistry. So they're a part of the hospital system, and there are groups of healthcare providers that work in that arena. But within the traditional dental office, it hasn't been set up that way. And I think as we look at the future of dental clinical care delivery, multidisciplinary group practices are becoming much more common. And so within that multi group practice setting, there could be really nice opportunities to bring on board, you know, other healthcare providers that are co-located in the same that's right, organizational structure. Some

Mariya Filipova, CareQuest Innovation Partners (33:08):

Of those models come to, to life. Some of the largest DSOs are going as far as integrating epic as a, as a, a dental record, e h r in the dental clinics. And specifically we know Pacific Dental, for example, is running medical clinics in some of the cases next to dental clinics to be able to better take care of some of those chronic conditions. I don't want to lose the point that you made about emergency room visits. Over half a billion dollar is spent on oral health related ED visits in Medicare alone. These are preventable visits, or likely because unfortunately our eds are not always well equipped to take care of a dental issue. And most likely the patient will be discharged with some sort of a pain management tool or antibiotics and will be asked to go visit and schedule a, a dentist appointment. And so if we're able to even focus on triaging and redirecting and helping those patients alone the savings in the system will be really meaningful.

Dr. William Giannobile, Harvard Dental School Dean (34:21):

Yes, yes. No, absolutely. And I think that, you know, this, this, this training aspect, it's not only on the, the oral healthcare provider side, but to help educate our physician colleagues. Many of them, they will only have one day devoted to oral health in their entire four years of medical school. But many of them are leading ER departments across the country and hospitals, and so there may or may not be dentists attending dentists in those specific hospitals. So what can we do to better train our, our healthcare providers in those settings?

Mariya Filipova, CareQuest Innovation Partners (34:59):

That's right. Training is one of them. I've I've also noticed that in, in my work specifically, we're looking to also remove barriers administrative barriers such as be having the right c p T code. So a primary care doctor or pediatric specialist could apply silver diamond fluoride to arrest cavities in, in young patients. And being able for a, for a primary care physician to apply what is effectively a rinse or a paste on the tooth and then be able to bill for it, is really important step in encouraging some of those behaviors on the medical side that would serve as preventative me measures on the dental side and, and similarly mm-hmm. <Affirmative> Dean Giannobile, you actually touched on the, the disconnect between preventative care versus much more invasive and interventional care on the oral health side.

(36:00):

 We are seeing many solutions now that are coming up in the market that allow us to identify oral health issues early, like diagnosing caries lesions. Currently the standard practice if, if care is to see the lesion, and perhaps when it's big enough to put in a filling, we know there are different solutions on the market, like a peptide P11-4, also known as Keon, that could talk about regenerative medicine, regenerate guided regeneration of enamel. So that early lesion gets rebuilt. The enamel rebuilt itself in a, in layman's terms, if you will. And so being able to have a code that allows dentists to build for that solution didn't exist before. So I'm very proud of the work that we've been able to do in that space where it, not only are we able to identify and validate those preventative innovative solutions, but then also allow the, the system that wasn't designed to accommodate for some of those innovative solutions to catch up and have the billable codes to, to make sure that those behaviors we wanna drive are there.

Dr. William Giannobile, Harvard Dental School Dean (37:11):

Yeah, absolutely. And we're seeing that, you know, within the Medicare space, there's, there's been many different efforts you know, advancing from the Affordable Care Act with our seniors on, you know, the provision of care. You're using the example of silveria fluoride with our pediatric patients, and how can pediatricians, pediatric dentists work together from an educational standpoint and other outreach areas. And as you just gave the example with the Keon technology, some of these early stage therapeutics that can be delivered very close to this juncture point of, you know, finding at risk patients, because we can identify what many of those risk factors are with our young patients and different patient populations to have a more engage a better engagement on their preventive recalls and assessments, then you can intervene at an earlier stage where you're not talking about endodontic therapy. Yes, sir. Crown and bridge type of work, or even to the end of tooth extraction.

Mariya Filipova, CareQuest Innovation Partners (38:22):

That's right. I I'm, I'm very excited about the examples you, you mentioned. I also appreciate that we've called out a couple of opportunities for innovators bold entrepreneurs to take on some of those challenges and gaps in care that we're seeing in oral health. And in your astute career, you've actually also served on not only as a researcher and innovator, but you've also served as an advisor for the FDA on dental devices. And so if I could ask you to think through all the different roles of in your career could you give us some examples of solutions that you see very promising or, or technologies that I see very promising, both on the dental side, but even more so on the medical side. Last year, we had over 20% of our SMILE Health cohort of medical companies and solutions that we were testing to see if there were use cases on the oral health side. I'm a firm believer of innovation across silos and disciplines. So what examples of promising technologies come to mind for you that on the medical side, it could be used on the dental?

Dr. William Giannobile, Harvard Dental School Dean (39:34):

Right. So, you know, this becomes an an interesting point because for myself, being a member of the FDA Advisory Panel, they're not a large number of dental technologies that come through through a PMA or a new drug or new device. Mm-Hmm. exemption. And so how do we get more dental technologies through the pipeline? And oftentimes this occurs when a medical device or a new drug is used for other applications in medicine. So great examples I can use are these regenerative factors like the bone morpho, genetic proteins, platelet derived growth factor. These are both growth factors that were used in medicine BMPs for spinal fusion to treat fractures and parts of the skeleton. And then eventually an application put forth for extraction socket healing, sinus floor augmentation, platelet derived growth factor being approved for neuropathic diabetic ulcers, also in orthopedics, and then in dental for periodontal regeneration.

(40:47):

Those are some examples. And as we look at some of our collaborations with companies, they see that path as one that is, is a little bit lower stakes, where they find that, again, this relates to the medical dental integration where there's this opportunity. And so personally, over the past couple of years, we've been collaborating with those bone health specialist companies that are looking at bone anabolic agents that can increase bone mass, that not only help patients prevent vertebral fractures and radius ulnar fractures. Yeah. But they also increase bone mass to allow dental implant placement and have these re these other downstream effects of increasing mass in the jaws. Maybe tooth retention, it hasn't been shown, but could be impacted as well. So those are some examples from, from that standpoint.

Mariya Filipova, CareQuest Innovation Partners (41:43):

And for those of us those of the entrepreneurs out there listening, these are great examples that again, with leaders like Dean Giannobile on the engaged in the FDA review and the advisory board, there is a path to raising awareness about the opportunities in oral health. I, I, I know that the FDA has been, we always like to kind of use the FDA as the, the, the big shadow of a delay. And if you need an d a clearance, this is a, this is gonna be a showstopper. But in many ways, we've seen the FDA being progressive, especially when it comes to approving some of the software as a medical device the solutions, and especially when there's a, there's a predicate and there's a established need, right? So I would encourage folks not to be discouraged by the need to, to have a FDA pathway through your innovation. In the course of the SMILE Health program, it's only 15 weeks. We don't think we could actually take that challenge on as part of, of SMILE. But if you need FDA clearance, that shouldn't deter you from applying and taking on that innovation opportunity.

Dr. William Giannobile, Harvard Dental School Dean (42:56):

Yes. And I think, Mariya, as you bring up this point, I think that there are many organizations that collaborate with dentistry in terms of providing some of this guidance. So we do work with regulatory experts, but those also involved in clinical adoption as, you know, it's, there's the clinical need and then there's the need from the, the scientific standpoint of the new technology and how can this work together. So we bring together engineers and scientists with clinicians to come up with that clinical need that can impact practice. And so when you look at the end in mind, how would this technology get into the clinic and how would it be adopted? Because that's, that's the highest hurdle. And so, as a part of our regenerative medicine resource center, it's a collaboration with the VCE Institute at Harvard, university of Michigan and the University of Pittsburgh. And we collaborate with a many individuals in the industry to help de-risk technologies. And some of them, there are great idea, but the regulatory pathway may discourage others. And then you wanna look at that bar to be able to meet that reduce that hurdle to get into the, the proof of concept that eventually you would hopefully be a game changer in the field.

Mariya Filipova, CareQuest Innovation Partners (44:20):

That's, that's, that's spot on. And I'm glad we were able to touch on this. So perhaps in the interest of time, I've been following the chat what a great, rich list of questions and insights in the chat. So thank you everyone who's been active and engaged in the discussion. I will I will try to cover a couple of the questions as we go through that are clustered around similar themes. Dean Giannobile, I see some, a handful of questions around financial incentives and incentives for both dental practices, large DSOs you know dentists to move from that fee for service transaction-based model to more restorative or value of restorative to a preventative model. Currently, the system is designed to encourage those restorative procedures. And so we will require system change in many ways workflow changes and sy and financial incentives. So what are your thoughts on what are the key pieces that we need to move towards that end state that you and I described? More preventative, right? More proactive.

Dr. William Giannobile, Harvard Dental School Dean (45:31):

Right. I, I think as you bring up the point you know, the existing dental reimbursement model is really insufficient to address all of these various need needs. And so I think that, you know, the obvious, obviously the healthcare integration, if we can have the opportunities for interprofessional clinical care delivery, that is, that is one of the obvious ones. And you gave the example Pacific Dental Services and other large DSOs that are looking at medical, dental integration models for the billing piece. Once one gets through that aspect, that will be a game changer in the delivery of care. And then I think looking at a couple of these questions here, individuals asking about that, we can use a couple of examples in dentistry. If you take the use of dental implants, which we've recognized that it's an expensive therapy, but it, it was eventually driven by a high demand from patients when dental implants were found to be predictable, right?

(46:40):

So once they became predictable and training programs expanded for dental implant reconstruction, patients were willing to pay for that technology. And we acknowledge that very few dental insurances pay for it, but there's a, there's a high utilization of dental implants in the US and globally. But as we look at the more preventive services, I do think as we can collaborate more with medicine, use the S D F example mm-hmm. <Affirmative> oral cancer screenings and others that, you know, as these diagnostics can be demonstrated to be cost effective you know, that's where dentists are not so familiar with, you know, implementing diagnostics, seeing questions here, periodontal disease, dental caries, two very common ones, if you can break through on those more rapid diagnostics, but it's going to take some innovative policy makers to, to break through in that dimension.

Mariya Filipova, CareQuest Innovation Partners (47:46):

And I also would like to clarify a common misconception. We, when we talk about, and I've seen this both in my time on the medical side and now on the dental side, when we talk about payers in a homo homogenous way, we need to understand the different nuances of the ultimate payer. We have government programs like Medicare, Medicaid, that have different, follow different standards and policies when it comes to reimbursement. And we have commercial payers. And what we fail to sometimes appreciate on the commercial insurance side is that in many ways, the commercial benefit provider is not ultimately the one who defines what benefits an employee would have. It comes down to the self-insured employers, and I believe that's it. My, my view is that we have an underappreciated stakeholder at the table, which are the large employers, especially when it comes to oral health that could drive decisions and make meaningful changes in the way we reimburse and what we benefit when it comes to preventative care.

(48:50):

I'll give you exam, another example, and we'll quote that study in guardian run a study between 2011 and 2017, where they looked at self-insured employers and their dental claims, and they categorized insurance employers based on preventative models of employers who were reimbursing different number of cleanings instead of two, four number of NU four cleanings a year. And and a non-pro preventative care model insurance employers. And so the employers who were categorized as preventative employers or models of care, they were spending on average about 36% higher cost on preventative services. Those same employers, however, were spending on average, over 80% less on, in inter in interventions that were, the interventions that were more expensive and, and, and more surgical in nature. And so, when we think about the case study for preventative care over more invasive care, this is a very it's a prime example. Now, the caveat is it took five years of data, 26 years of data, 2011 to 2017 to be able to see the trend. And so that's where we as business leaders and executives and thought leaders and researchers and innovators have a role to play to be able to come up with those solutions and have little bit more of a longer term view because the math clears the business case. Is there.

Dr. William Giannobile, Harvard Dental School Dean (50:22):

Absolutely. I mean, the, what you've just given an example of is that the un I would just underline the point, the long view versus the short view. That's right. And that's where we're seeing these impacts within oral systemic diseases. They do, again, they don't happen overnight. And if the, the various types of third party payers, governmental insurance groups recognize that, again, we have these innovative policy makers who can bring them together.

Mariya Filipova, CareQuest Innovation Partners (50:51):

That's, and, and and thank you for the questions along that line. I can, again, it goes back, we're almost full circle. We look for innovations and solutions that allow us to connect the dots between dental interventions or interventions on the oral health side, that in impact overall clinical outcomes, overall health outcomes, even if they're on the medical side. I believe we have a q a time for one or two more questions. So perhaps we we, we do, we, we take that as a I'll, I'll, there are two things that I would like to probably touch on. Dr. Giannobile. Could we maybe talk a little bit about the role of data interoperability in in, in as a tailwind, if you will, to help drive some of those connections between medical and dental care and even advance some of those preventative payment models. What do you see the opportunities and the gaps, and what are the things that you are encouraged by today?

Dr. William Giannobile, Harvard Dental School Dean (51:53):

Right. So what we see is that most of the clinical, the large clinical studies done in dentistry some of them are multi-center investigator initiated clinical trials, and they're on the order of dozens to hundreds of patients. And they're really insufficient for us to be able to make significant claims on. And so I think it's going to be important to take advantage of big data, and we're seeing this with large DSOs. We're seeing it with insurance companies that have access to data. And then the next stage is to have quality data to, to go through those data to make sure that they are of the quality that then one can look to integrate the, the dental information there. And so we've seen ai, machine learning technologies being able to cluster together and using data science to ient, you know, to identify trends in associations that, I mean, obviously you need prospective studies to de you know, determine if there's causality.

(53:06):

But I think data science will open up a lot of these areas that I think that the third party payer environment will, will take note of and listen to this in the provision of care. I think that will speak for itself. That's fine. I, I did see was a question here on medical, dental integration training and how really it has not been successful. I would, I would agree with this point in that, you know, from a public health standpoint, and several people brought up the cost component Yeah. On where that is certainly from a public health standpoint in mobile dental care or going out into communities, more rapid screening programs for diseases could be beneficial to then bring those patients in and using other types of models of clinical care delivery, I think is a good point.

Mariya Filipova, CareQuest Innovation Partners (54:04):

It's, it's a, it's a critical point to think about education as an opportunity and, and frankly, meeting patients where they are goes back to our original point of care does not have to happen only in the dental chair, in the dental office. Yes, it happens in the community, in the church, in the school. And we're seeing multiple successful models that are what I would consider prime to be scaled. Right. And what, and, and we, we have to remember that a model that works in a single county, in a single state may need to be adapted to work nationwide. However, there are enough examples of successful models in mobile care delivery. And d you mentioned AI as a decision support tool, as a visualization tool, as an insights generating tool, maybe even diagnostic tool as a screener. And I, I would love to also highlight technologies like tele dentistry and ability to see patients virtually that if anything, covid did show us that this is feasible definitely on the medical side, and we have some work to do to expand that on the dental side.

(55:16):

But when I think about some of the questions we started with, how do we triage patients away from ed high cost, low efficacy interventions like visit to the ED for oral pain I think virtual care network could could, could be a very good solution in, in that specific example. Great.

Dr. William Giannobile, Harvard Dental School Dean (55:38):

Yes. Yeah, I was and I'll provide this link. I was just looking to pull this up for you. In terms of, you know, ai, I mean, we we're, we're very much trying to figure out all of the opportunities with ai. We will have a global symposium yes. Here at Harvard in the fall on that and really bringing together, you give the great examples of using telehealth looking at AI with large databases, and then we have all the imple implementations as it relates to you know, how the FDA is going to assess these technologies. Dentistry has been leading as it, as it relates to diagnostic imaging. And then as we look at pathology, and then eventually in patient stratification looking at risk. And so you know, this is where a lot of our younger colleagues who are getting involved, we have our Kempner Institute at Harvard that, you know, launched by the Zuckerberg Chan Foundation to really promote ai. And the major focus is on training the next generation as we, as we recognize with our young people, their ability to take in it and adapt using AI machine learning technologies. And I think with the big data that will eventually become very important,

Mariya Filipova, CareQuest Innovation Partners (56:59):

That's ex extremely important. Thank you for flagging what a great opportunity to get deeper into the potential untapped potential of AI into in dentistry. Again, for those of you who are looking to get exposed into that topic the, the symposium at the Harvard School of Dental Medicine is a great way to do it. It's November, early November, November 3rd and fourth here in Boston. I can't thank you enough DLI for being with us today. What a great start of, of our Monday of the week here. I'm very excited, also and grateful for the highly engaging conversation. And so for those of you who want to stay engaged please look for the replay and the notes of the replay link. This is where we would tag all the studies that we mentioned today, as well as some additional resources that you might want to consider in the initiative that Dr. Dean Giannobile and his team are leading across medical, dental, integration and entrepreneurship. So thank you again for joining us today, Dean Giannobile. And with that, I would now hand it back to Jeana who is our partner in crime and a leader at MATTER Health, who's been helping us lead the effort on multiple fronts when it comes to small health. Thank you, Jeana. I'm heading it over to you.

Jeana Konstantakopoulos, MATTER (58:37):

Amazing. Well, thanks Mariya, and thank you, Dr. Giannobile. Believe for a fascinating discussion. Join us in our mission. We're thrilled to have you. And thank you for joining us today.