FILLING A

VOID

FEBRUARY 2025

CONTENTS

GLP-1

agonists

& weight loss

THE ORAL MANIFESTATIONS AND COMPLICATIONS RELATED TO DIABETES MELLITUS ARE WELL KNOWN TO INCLUDE XEROSTOMIA, CARIES, PERIODONTAL DISEASES, ORAL CANDIDIASIS, BURNING MOUTH, GLOSSODYNIA, DYSGEUSIA, GLOSSITIS, ORAL LICHEN PLANUS, RECURRENT APHTHOUS STOMATITIS AND DELAYED WOUND HEALING.^{1, 2}

Diet and obesity are major risk factors for diabetes. Approximately 70% of American adults are either obese or overweight.³ Recently, glucagon-like peptide-1 (GLP-1) receptor agonist medications used to control diabetes have been shown to help with weight loss. These medications have become popular for weight control, even in patients without diabetes.⁴

Semaglutide is a GLP-1 receptor agonist approved by the FDA in 2017.⁵ There are three FDA-approved semaglutide products. Ozempic (injection) and Rybelsus (tablets) are approved to lower blood glucose levels in adults with Type 2 diabetes mellitus. Wegovy (injection) is approved for obesity in adults and children aged 12 years and older.⁶ Recently, GLP-1 agonists have been shown effective in decreasing body mass index and maintaining weight in children.⁷ GLP-1 receptor agonists mimic the GLP-1 hormone released in the gastrointestinal tract after eating. One function of GLP-1 is the stimulation of insulin.

Zepbound.¹⁹ Tirzepatide interacts with a second receptor, glucose-dependent insulinotropic polypeptide (GIP), to affect insulin and blood glucose levels similarly to GLP-1.²⁰ Also, GIP delays stomach emptying by decreasing gastric motility.²¹ This is like the effect of bariatric surgery; however, Tirzepatide has not been shown to be as efficacious as bariatric surgery.²² Unlike semaglutide, Tirzepatide has not been shown to reduce the risk of heart attack or stroke.²³

Diabetes mellitus is a risk factor for other chronic diseases such as dementia, sleep apnea and certain obesity-related cancers.²⁴ A systematic review supported a reduced risk of dementia in patients taking GLP-1 inhibitors for diabetes.²⁵ In 2024, Eli Lilly released results from two clinical trials comparing Tirzepatide to a placebo over the course of a year. The trials showed that GLP-1 medications can reduce sleep apnea events by up to two-thirds.²⁶ GLP-1 medications were also associated with lower risks of specific types of obesity-associated cancers (gallbladder, meningioma, pancreatic and hepatocellular carcinomas) compared with insulins or Metformin in patients with Type 2 diabetes.²⁷ A cohort study by Wang et al showed GLP-1s were associated with a lower risk for colorectal cancer in patients with obesity.²⁸ These findings provide preliminary evidence of the potential benefit of GLP-1s for certain chronic diseases and cancer prevention in high-risk populations.²⁹

The potential health benefits of GLP-1 agonists for people with diabetes seem to outweigh the potential side effects.³⁰ The same may not be true for weight loss. Obesity is not caused by Ozempic deficiency.³¹ The expectation is only 15–20% weight loss, and the results must be maintained with the drug.³² Although the adverse effects are rare, given the wide use of GLP-1 agonists, the effects must be considered by patients contemplating weight loss. Even though we have keen, expert celebrity endorsement³³ (sarcasm intended), GLP-1 agonists, while useful, should not be considered a panacea for weight control. The high cost of Ozempic, approximately $1,200 a month, poses a financial barrier for many, potentially limiting access to and continuation of treatment.³⁴ Currently, there are no approved generic versions. Semaglutide is expected to come off patent in the United States by 2031.³⁵ However, there are reports of counterfeit Ozempic pens being sold. The FDA has issued warnings.³⁶

Obesity is a multifactorial disease due to obesogenic environments, psycho-social factors and genetic variants.³⁷ The answer may not be as simple as an injection or tablet. We need less judgment and more options. While GLP-1 agonists may be useful adjuncts, behavior modification, counseling, proper diet and exercise continue to be the best advice for long-term health and continued success.³⁸

Another function is glucagon reduction, further decreasing blood glucose.⁸ GLP-1 in higher amounts suppresses appetite and signals a feeling of fullness.⁹ Ozempic is not approved for weight loss. However, semaglutide has been approved for weight loss under the trade name Wegovy.¹⁰ Wegovy has a larger dose of semaglutide than Ozempic. GLP-1 agonists generally result in an average weight loss of 15–20% of total body weight.¹¹

Research has shown that discontinuing Ozempic (or Wegovy) results in gaining back the lost weight.¹²

Semaglutide is the first GLP-1 receptor agonist shown to decrease the risk of heart attacks and strokes among those without diabetes.¹³ Treatment with drugs like Ozempic requires a lifelong commitment. Side effects, including nausea, reflux, abdominal cramping, delayed gastric emptying and constipation, may contribute to patients discontinuing the medications. More serious but less common side effects include pancreatitis, gastroparesis, bowel obstruction and gallstones/bile duct blockage.¹⁴

Investigators were quick to point out that the risk varies depending upon the reason why the drugs were being used (diabetes, obesity or weight loss).¹⁵ A rare case of Rhabdomyolysis was reported in the literature in 2023.¹⁶ Recently, an observational study published in the Journal of the American Medical Association suggested semaglutide may be associated with nonarteritic anterior ischemic optic neuropathy, a type of eye stroke that causes sudden unilateral loss of vision.¹⁷ Unsurprisingly, semaglutide complications became popular with the legal profession¹⁸ as quickly as the drug became popular for weight loss.

Tirzepatide is another medication of interest. Tirzepatide was approved for treating Type 2 diabetes in 2022 under the name Mounjaro, and in 2023, it was approved for weight loss as

As dentists, you've seen the numbers on repeat. In fact, you likely didn't need to see the data to know there is a serious problem.

YOU LIVE IT EVERY DAY.

"As a dentist, I am not working at the highest scope of my license. Instead, I am doing other services that a hygienist or dental assistant would do," said Dr. Vinod Miriyala, an Ohio-based dentist with extensive experience in both public and private settings. "This is not an improving situation, and we have to do something more to address it."

At Delta Dental of Michigan, Ohio, and Indiana, we are acutely aware of the challenges dental offices face regarding staffing. Many of the topics of conversation during our editorial advisory panel (a group of dentists, hygienists and office managers from Michigan, Ohio and Indiana who meet to help guide Delta Dental's communications to providers, including this publication) have focused directly on staffing issues. The issue is top-of-mind for the dentists in our networks, and it is also top-of-mind for us.

The Delta Dental Foundation (DDF), in fact, has spent a great deal of time, effort and resources on the subject and is rolling out and designing several measures aimed directly at providing tangible relief.

In the previous issue of Best Practice, we featured a new chairside recruiting program dubbed Hygienist Inspired.

This multiyear initiative is a joint effort between DDF and the American Dental Hygienists' Association (ADHA). It aims to leverage the expertise of dental hygienists and the strength of their patient relationships to help open career opportunities—particularly for those in communities currently underrepresented in the profession.

Building from the momentum of that initiative, the DDF and Delta Dental of Michigan, Ohio, and Indiana are putting the final touches on several new initiatives aimed at making hygiene school a reality for dozens of would-be students while also reducing the financial burden on those who have already attended hygiene or dental school.

Here's a summary of the proposed program.

• A joint DDF and Delta Dental scholarship program for hygiene students to cover the cost of material kits and tuition
  
  
• Loan repayment program funded by the DDF for dentists and hygienists who commit to working in nonprofit clinics in Michigan, Ohio or Indiana
  
  
• Loan repayment program funded by Delta Dental for private practice dentists in underserved areas

"Scholarships, at least in terms of tuition reimbursement, aren’t enough," said Holli Seabury, DDF executive director. "We heard directly from dental hygiene programs that one of the biggest barriers students face is the cost of the materials kit they need to start the program. Financial aid and other scholarships often can't be used for those kits, which is why we want to address it."

For perspective, the average upfront kit/lab/uniform cost ranges from about $5,300 to as much as $10,000. For licensure, students must take national boards and pay state fees.

The total cost for these can top $2,000. And, of course, there’s tuition.

There are currently 33 dental hygiene programs across Michigan, Ohio and Indiana. The majority are two-year programs, while seven are four-year programs. One offers a three-year option, while another offers two- or four-year degrees. The average annual tuition is just over $9,000, with a completion cost of about $32,000.

Evolution of the issue

The pandemic. That's the easy answer to the question of what caused the hygienist shortage. But, there is nuance in the causation.

"I think we now know that the problem was pre-existing, but it reached a breaking point during COVID," said Miriyala, who serves on the DDF board. "The hygienist workforce predominantly consists of women. When it came to COVID, my experience was that they had to make a decision about taking care of family at home. They put their family first by cutting down hours or leaving the workforce, and rightfully so. Others took on opportunities outside of direct patient care."

DataUSA.io,¹ an online resource that compiles public data from U.S. government sources, shows that in 2022, 94.4% of hygienists in the nation were female.

Data from the Bureau of Labor Statistics reveals that women left the workforce at a rate nearly four times higher than men, with some 865,000 women leaving the workforce in September of 2020.²

When looking specifically at dental hygienists, an ADHA study published in the February 2021 issue of the Journal of Dental Hygiene³ found the leading concern (48.3% of the total) that led to a hygienist leaving their position was that they simply

didn’t want to work as a hygienist until the pandemic was under control. Caring for family was a cited reason for leaving but it was at a much lower clip—10.4%. Concern over workplace safety standards (12.7%) actually drove more hygienists away from the profession than did childcare concerns.

Bureau of Labor Statistics numbers⁴ indicate the number of people in the workforce has rebounded and is poised to surpass pre-COVID totals. But filling vacant hygiene positions, unfortunately, remains difficult.

"Initially, I thought things would die down after COVID and we would see things go back to normal. But that's not what happened. In fact, many (hygienists) left dentistry entirely," said Miriyala.

The basic economic principle of supply and demand came into play to combat the issue and try to retain current staff or attract new ones. Pay rates for hygienists climbed fast, but it didn't have the impact one might

expect. Despite the increase in compensation, the recruitment rate hasn’t met or surpassed the attrition rate.⁵

This is the primary reason Delta Dental and the DDF are working to create initiatives to bring new people into hygiene, and those efforts carry a very important sub-focus: diversity.

"We absolutely have to diversify. We need to make the profession more attractive to more people—of all types," Miriyala said.

Miriyala said he feels the Hygienist Inspired chairside recruiting piece is an excellent step and he is encouraged to hear that further efforts are on the way.

"The hygienist is the gatekeeper of our practice. They are the face of our clinical care. They see more patients, typically, than we do as dentists. They are the primary caregivers once a patient is stabilized," he said.

The numbers—sobering as they are—are worth repeating for context and perspective. 

• In a March 2022 American Dental Association Health Policy Institute poll,⁶ 73% of dentists cited staffing issues as the top challenge facing their dental practice. One-third of practice owners said staff shortages make it difficult to run a full schedule.
  
  
• In another ADA report, fewer than half of dental hygienists who left employment during the COVID-19 pandemic have returned.⁷

• ​Another report indicated a decline in dental hygienists of 8% overall.
  
  
• The Bureau of Labor Statistics projects a 9% growth in employment for dental hygienists from 2022 to 2032, further exacerbating the gap between supply and demand.⁸
  
  
• Nationwide, there's a projected shortfall of more than 23,000 full-time dental hygienists by 2036.⁹

NMU will study the feasibility of developing and sustaining a dental hygiene education program in Marquette to meet workforce needs of regional offices and enhance oral health services for Upper Peninsula residents. The closest existing program in the state is about 350 miles south in Big Rapids at Ferris State University. All U.P. dental societies joined in signing a letter of support as part of the application process.

“The need for talented individuals to help provide timely and comprehensive care is greater than ever, and the collective dental offices of the U.P. are not immune to the challenges that face health care today,” the support letter stated. “There needs to be an effort to develop, attract and retain talent. Establishing a training program here in Marquette at NMU would greatly improve the number of qualified providers and subsequently improve access to care across our region.”

“The existing dental hygiene programs have wait lists of three to five years, and few are positioned to support rural health needs,” said Elise Bur, NMU Center for Rural Health director. “Northern Michigan University has established strong dental partnerships with independent practices, tribal health centers and federally qualified health centers that strongly support this exploratory project. The potential to develop a hygiene education model that supports rural health could serve as a model for other rural areas in the nation.”

Because there are no dental hygiene programs in northern Michigan, Bur said individuals have to migrate out of the U.P. for training and may be less likely to return. When combined with the region’s aging population, she said this impacts the available workforce, access to and affordability of health care services, and economic development.

The DDF, which supports workforce development and access to care as key components of its strategic plan, sees this feasibility study as a chance for the U.P. to lean on local talent and home-grow its oral health workforce.

“Graduates from a dental hygiene program at NMU could effectively write their own tickets,” said Holli Seabury, EdD, executive director of the DDF.

“The demand for hygienists is huge, especially in the U.P. This will be an economic opportunity that improves oral and overall health in northern Michigan communities.”

According to the Michigan Health Council’s 2023 Health Care Workforce Index, it is harder to gain access to a dentist in some areas of the state than in others. In 21 counties, there are fewer than 3.5 dentists per 10,000 people. In another 20 counties, it is only slightly better—between 3.6 and 4.9.

“While Michigan’s overall ratio of dentists per 10,000 people is at the national average, people living in about half the counties in this state have far fewer dentists available. In other words, more than 1.7 million residents live in areas with a shortage of dentists,” the report stated.

Bur said the absence of a dental hygiene program in northern Michigan has exacerbated the impact of the overall oral health labor distribution in a more rural part of the state.

The feasibility study will be conducted in accordance with American Dental Hygiene Association recommendations. The project is expected to be completed by fall 2025.

If NMU determines, with input from local stakeholders, that a new dental hygiene education program in Marquette is feasible, Bur said future steps would include:

• Developing the curriculum and applying for NMU board approval
  
• Solidifying additional funding for implementation, faculty, space and supplies
  
• Marketing the program and recruiting students
  
• Securing Commission on Dental Accreditation approval

Bur said continued conversations will be required to gain additional regional and state legislative support in identifying funding sources to sustain the program.

This is a staple ingredient that will continue to play a prominent role in the recipe. Why? Because the work the DDF does is so very important, and it is work that we at Delta Dental are immensely proud of. It seemed only fitting that for this issue, in which we are unveiling a joint scholarship effort aimed at helping ease the pinch facing dentistry as it relates to hygienist availability, we also shine a light on Holli Seabury, executive director of the Delta Dental Foundation.

Seabury, who joined the DDF in 2019, has had a tremendous impact on the organization, bringing transformative energy and vision to her position while holding a razor-sharp focus on furthering the DDF mission to enhance oral health and access to dental care across communities.

If you are unfamiliar with the relationship between Delta Dental and the DDF, it can be helpful to understand this mission focus.

Delta Dental of Michigan, Delta Dental of Ohio and Delta Dental of Indiana are each nonprofit organizations with the mission of improving oral health through benefit plans, advocacy and community support.

The DDF complements this with its mission focus of improving equity in oral and overall health. To achieve this, the DDF focuses heavily on efforts and initiatives that will improve access or oral health care for all.

“Our missions are complementary. Delta Dental provides the benefit plans that make oral health care affordable for millions of people,” Seabury said. “The DDF works to make sure people can live their best, healthiest lives, no matter who they are or where they come from. For those with dental benefits, we want to make sure they’re able to utilize them. For those without benefits, we want to make sure they have care available to them as well.”

Seabury joined the DDF with a strong public health and education background, including serving as CEO of a national health education nonprofit, allowing her to bring a strategic, community-centric approach to the organization.

The DDF serves Michigan, Ohio, Indiana and North Carolina and is funded in part by corporate giving from the Delta Dental member companies in those states in addition to charitable contributions from private citizens and corporations.

The numbers are impressive, and the impact is palpable. In 2024 alone, the DDF provided grants that helped more than a million people. And those numbers continue to grow.

The DDF’s 2024–2028 Strategic Plan envisions a world where everyone has access to high-quality dental care that meets their comfort level and abilities across the lifespan. To make that happen, the DDF developed five strategic aims (access to care, advocacy, education, emerging initiatives, workforce development) to guide its grantmaking efforts, with oral health equity for people with disabilities as the cornerstone.

“We have an engaged and passionate board of directors and a plan that is focused and encompassing,” said Seabury. “We are doing the work that can make a real difference, and that’s what this is all about.”

In this issue, you’ll learn about a developing scholarship program aimed at making hygienist education more affordable and accessible to bring some relief to the current hygienist shortage facing our industry.

Here are just a few of the other projects made possible by DDF funding:

• Chairside hygienist recruiting program in partnership with the American Dental Hygienists’ Association

• Corktown Health, the first LGBTQ+ affirming nonprofit dental clinic in Michigan

• GuardCare 2024, a free dental care event provided by Ohio National Guard personnel

• Cuyahoga Community College Foundation support to equip its Ohio dental hygiene program expansion and reduce their student waiting list

• Shelter Association of Washtenaw County support to provide dental services to people experiencing homelessness in partnership with University of Michigan School of Dentistry

• Matthew 25, Inc. to provide free dental care to low-income and uninsured people in Fort Wayne, Indiana

• ​McMillen Health support for the Brush oral health program for children, caregivers and adults with chronic health conditions in Michigan, Ohio, and Indiana

“We’re proud of the work that we do, but there is so much more to be done,” Seabury said. “This isn’t work that we do alone by any means. Without our partners, we don’t do this. Without the support of Delta Dental member companies, we don’t do this. And without the network dentists who are on the front lines of oral health care, we can’t do this.”

In a previous issue of Best Practice, we shared a link to a survey in which we asked for your interest in access to assets that could be used to enhance the social media accounts of your businesses.

The response was outstanding, and we are excited to release a new social media toolkit for use by in-network dental offices.

The toolkit features graphics focused on oral health topics and dates. The assets are completely free to use and can be utilized on any social media outlet. Consider tagging Delta Dental of Michigan, Delta Dental of Ohio, or Delta Dental of Indiana when posting to help boost the reach of your posts.

The kit will be updated periodically, so be sure to check back often.

Check out the summaries by visiting your state's
CE course webpage:

• Michigan: www.deltadentalmi.com/courses
• Ohio: www.deltadentaloh.com/courses
• Indiana: www.deltadentalin.com/courses

If you’re looking for continuing education credits,
here’s a reminder that Delta Dental of Michigan, Ohio, and Indiana has you covered. Our free CE courses are available online, and we’ve added three new offerings.

PACT: SEAMLESS
SELF-SERVICE CREDENTIALING

DELTA DENTAL OF KENTUCKY HAS A NEW PORTAL

Even if your practice is located in a state other than Kentucky, you may have Delta Dental of Kentucky members if they are employees (or a dependent) of a business headquartered in Kentucky.

Please note that Delta Dental of Kentucky has updated to a new dental portal to verify insurance coverage of Delta Dental of Kentucky patients.

Please use the Dental HUB for all Delta Dental
of Kentucky patient information.

Follow the steps below to verify benefits for patients with coverage from Delta Dental of Kentucky.

1. Go to deltadentalky.com.
   
   
2. Click "Sign in/Register" in the upper right-hand corner and select the option for employers, dentists and producers.
   
   
3. Select the option for "Dental HUB."
   
   
4. Click on "Sign in With Delta Dental" and log in through your Delta Dental account.