Chuck Cohen: Hello, everyone! Welcome to another edition of Driving Dentistry Forward, the podcast where we talk to the leaders of dentistry. Today, our guest is Dr. Kady Rawal. She’s originally from Mumbai, India, and she’s a graduate of dental school in India, and she’s done her residency in the United States.
She’s currently a professor at Boston University and Harvard Dental Schools. Her specialty is geriatric dentistry, and that’s where we’re going to focus on today mostly. Good afternoon, doctor. Glad you’re here. Thank you for being here with us today.
Dr. Kady Rawal: Thank you so much for having me.
Chuck Cohen: Excellent. Well, talk to us about your personal story from India to the United States and how you got interested in dentistry, and how you got interested in geriatric dentistry.
Dr. Kady Rawal: Oh, absolutely. I get asked that question a lot, especially now that there’s a lot of interest among students and newer dental grads in the field of geriatrics and treating older adults with the boom in the older adult population.
So, as a child, I was very inspired by my mom, a family physician. She’s going on her 40th year as a family physician. So, I would hang around her office, at her clinic, all the time, and she inspired me. But growing up, my father was an engineer, and he always saw that I was inclined towards artistic things and building.
test when I was 15 or 16 years old, still in high school, about what would be the best career that would fit all of my talents and all of my skills. Between medicine and engineering, dentistry is a perfect amalgamation of the two. And so that’s how I got inspired and interested to become a dentist.
While I was in dental school, I believe I was in my second year of dental school; my grandma got diagnosed with Non-Hodgkin’s lymphoma. And although it’s a multi-organ disease and a lot was going on in her body at the time, one of her chief complaints was dental. She had a lot of dental issues, a lot of periodontal issues.
Unfortunately, at that time, she went from dentist to dentist, specialist to specialist in Mumbai, which, as you know, is a huge, cosmopolitan city with extremely trained professionals. And none of them felt confident treating her or taking on the liability of an older adult living with co-morbidities and treating her in the dental chair.
I was still only in dental school, so it was very difficult for me to help her. She passed a couple of years after. That’s when I decided that no older adult should have to go through that, and there should be care available for older adults living with co-morbidities. And that was one of the fields that I wanted to take on. And I wanted not just to learn more within that field and provide that service. But I knew right then that I wanted to teach it to others so that this would not happen as much as it does, unfortunately, in many parts of the world.
Chuck Cohen: Well, talk to us a little bit about how you came to be in the United States from India, where you got your education, and where you were born?
Dr. Kady Rawal: Sure. So, again, there were very few countries worldwide that were teaching geriatrics within their residency programs. And this was in 2007 or 2008, which is when I started my process of thinking about what I wanted to do next. I was still in dental school, but I was kind of wrapping up dental school, and I wanted to chart my path forward.
So, the United States was one of my top choices, simply because they taught geriatric dentistry, and there were programs available in which you could learn so much more about it. I had read so many papers, but so many specialists were practicing it, teaching it, writing about it, researching in it. And of course, since 2009, there has been a different trajectory within the field of geriatric dental medicine as well, and I’m so glad that I could have been a part of it. So that’s what brought me to the United States.
Chuck Cohen: That’s excellent. So talk a little bit about geriatric dentistry as a specialty. It’s not a specialty per se like orthodontics or endodontics. Do you think it should be a specialty? And if so, or if not, what makes it different than practicing, let’s say, general dentistry?
Dr. Kady Rawal: Got it. I do this a lot, so I hope you don’t mind, but I’m just going to correct you there. Instead of calling it “geriatric dentistry,” I would love for everyone to adopt the term “geriatric dental medicine” because it is so much more than just a procedure; we try to look at the patient as a whole body.
We are one of the many medical providers for our geriatric patients because, as you can imagine, at that age, a lot is going on with several systems malfunctioning, especially with our older adults who are living with co-morbidities. We work as one wheel or one cog in the larger mechanics of things, so we work very closely, providing interprofessional care with geriatric physicians. We also work with geriatric nutritionists, geriatric speech pathologists.
We also work very, very closely with geriatric physical therapists. Something as simple as how to hold a toothbrush or make the toothbrush a little bit better to make our older adults a little more independent and able to care for themselves. And so we are just one little cog in the larger machinery. And that’s why I’m going to correct you and say “geriatric dental medicine.”
Chuck Cohen: Correction received, no worries. What’s the age group that we would say “geriatric” applies to?
Dr. Kady Rawal: Again, that’s a question I get asked a lot. And I will tell you that when most persons are called “older adults” at the age of 65 and over, geriatrics is a little bit different because, in the field of geriatrics, we consider a patient to be geriatric with not only age as a factor, but they also must have some other disabilities, some other co-morbidities that are going on.
Most of our patients are frail, older adults that are medically compromised. They have a long list of medications. So, I also treat older adults who live in their homes. They may be 90 years old, then drive their own car. They make their own dental appointments. They show up on time. And so that patient I would call an “older adult who is community-dwelling,” whereas patients we treat at a long-term care facility who need others to provide care for them. Patients who have this long list of medications or may use wheelchairs or use a cane, may use a hearing aid and are also 90 years old but have all of this other stuff going on; I would refer to them as “geriatric patients.”
Chuck Cohen: So, it’s more along the lines of physical capabilities that make them geriatric or not. Interesting. What are some of the dental challenges that geriatric patients face that you deal with all the time? And then how do you deal with them?
Dr. Kady Rawal: Right. So there are, as you can imagine, if you have teeth in your mouth for 100 minus six years, for an 84-year-old and we do it a lot of centenarians in our practice, they must have something that must have happened to or something’s going on with them.
The good part is that, in the past 10 or 20 years, the edentulous rates, meaning older adults who have no teeth, those rates are falling. And so, adults are getting older, having lost fewer teeth and having most of their teeth in their mouth. Now, this causes new issues. Now there are periodontal problems that didn’t happen before because “no teeth, no periodontal problems.” There are restorative problems. There are caries concerns, which means there’s more decay around the teeth, teeth breaking down. And all of these are issues that can happen.
Now also imagine an older adult who is on multiple medications or an older adult who has several other systemic failures that are going on, either liver failure or diabetes, all of these other things going on. And we know the mouth is the portal to the body, so all of these things are reflected in their mouths.
One of the biggest challenges that those of us who treat geriatric patients experience is managing the multi-system conditions that are going on. And how do we address the dental concerns while keeping in mind that these patients cannot provide care for themselves? They’re dependent on others to provide this care for them. How do we provide the best dental care for them when we know that they have several other systems in their body that need to be addressed, or when other medications are going on and may negatively impact their oral health? And these are medications we cannot stop. So now there are all of these things like dry mouth, which is very common.
Patients will come in saying, “Oh, six or seven years ago, I was not taking any medications. Now, I’m on this big list of medications, and all of my teeth are failing. They’re moving. There’s decay everywhere. I can’t use my hands as well as I used to. I’m dependent on someone else even to brush my teeth and comb my hair.” And so, these are some of the common challenges that we face.
As a geriatric care provider, one of the biggest challenges I face is: how do we provide comprehensive care to these patients most often in wheelchairs? Because very rarely are we able to transfer the patients. Sometimes we transfer the patients, but we need to ensure we provide quality dental care to these patients while treating them in their wheelchairs and sometimes in hospital beds, which is very different from what general dentists do because your work position is different. The way you would address the patient is very different when the patient is not in a traditional dental chair that you see behind me right now.
Chuck Cohen: Absolutely. Well, just hearing you talk about it, I’m inspired. The inspiration comes from the thought that 90 years ago, when my grandfather started Benco in the 1930s, in the United States, most of the business was in artificial teeth because, at the time, it was not unusual for adults to lose all of their teeth or a good portion of their teeth when they were in their 40s or 50s.
The idea is that today, three generations later, less than a hundred years later, you’re trying to figure out how to take care of patients who have their teeth for a hundred years or more in their mouths and that those teeth are still functioning. It’s, I think, a triumph for dentistry.
Dr. Kady Rawal: Absolutely. It’s also a triumph for how our society has succeeded and formed. Now there’s fluoridated water, which you know, didn’t exist back in the day. Also, people are more cognizant about taking care of their health. They are beginning to understand that the mouth is as much a part of their body as any other organ. They are seeking dental care earlier on. Patients who would have never considered getting implants are now getting implants.
You’d be surprised how many patients I have over the age of 85 or 90 who have successfully had implants in their mouths. And now it’s our job at the other end of the spectrum in geriatrics to maintain these implants and maintain the prostheses that are now placed on these implants. So, yes, life has changed quite a bit.
Chuck Cohen: Very exciting, actually. I think it’s kind of cool. What are the two or three things that you would share with other dentists who are thinking about treating geriatric patients regularly?
Dr. Kady Rawal: First of all, I would say everyone should welcome older adults in their practice simply because there is a very, very high need among the older adult population to address their oral health concerns, but also that population, the baby boomer population is truly booming. And so it’s almost going to be impossible, if not already then a few years from now, for a dentist to say, “I don’t treat older adults” because that’s going to be every dentist’s bread and butter if you think about it.
A lot of our patients also have invested well, and a lot of times, patients will come in and say, “I don’t care what this costs. I wanted the best teeth in town. I want my smile. I want to be able to whistle. I’m going to go on a date next month. I need my beautiful smile. It’s as much as part of my body as the rest of my face, and it’s the first impression that they make.”
Even though now there’s a pandemic and everyone’s wearing masks, you’d be surprised how many older adults are very, very hopeful that this pandemic will end soon. They’ll come in, and they’ll say, “Fix all of this before the masks go away so that, when I take my mask off, I can flash my beautiful smile at everybody.” So I would tell all of the dentists to absolutely welcome older adults in their practice.
Regarding how they may need to adapt their practice model, it’s very important to know that older adults need more chairside time. That does not mean that you may be doing more dental procedures, but it means that we usually take extra time to go over their medical history. They may need to pause and take several breaks. They may have a lot more questions about their oral health than an adult patient.
You may have to step away from the patient or make a call to their medical provider to say, “Hey, I just saw that all of these medications are going on. This is the procedure I’m going to do. Do I need to prepare for something in particular? My patient is on blood thinners, and they just told me their medical history, and now I have to go ahead and do this extraction. What do I do?” So, be prepared to give that older adult extra chairside time. That’s something that dentists may have to work into their scheduling on how they will see older adults.
Chuck Cohen: More time is very important and more patience, I would assume. Because sometimes older Americans, older patients, need a little more patience, right?
Dr. Kady Rawal: Absolutely, absolutely. It’s a lot like pediatrics—the other end of the spectrum. But yes, maybe they need that time and patience.
Chuck Cohen: Talk for a minute or two about the challenges that adult or senior patients have regarding home care. I’d imagine there are some times when you can do the best job possible in the chair, in the dental laboratory, but then the patient goes home, and they can’t take care of their teeth as they’d like to or like they should. And how do you overcome that?
Dr. Kady Rawal: Right. So a lot of times, at the dental appointments, we will have the caregiver, the primary caregiver, attend the dental appointment as well. There are maybe several issues at hand. The most common one is cognition. So many of our patients that are maybe in a cognitive failure, may not even be able to repeat instructions right after you’ve given it to them.
So one of the things that you need to evaluate at the very first consultation appointment is “how much can you rely on the patient’s cognition to be able to repeat and reproduce the care instructions that are given?” And in that situation, it’s always better to repeat these care instructions to the primary caregiver at home. Sometimes, a spouse is the same age as the patient but has better cognition than the patient. Sometimes they have adult children who you might be able to contact.
So, home care is extremely important because It’s a preventive barrier; it prevents further disease and helps maintain whatever care you, as a dentist, have provided in the dental office. In a nursing home or a long-term care setting, the situation is different because we have round-the-clock medical staff or nursing staff providing care. So in this type of situation, what we do is provide educational lessons.
We do continuing education for the nursing staff to go over the common barriers, how to overcome them, how to look into every patient’s mouth, how to help them brush their teeth, clean their dentures so that we’re not 100 percent relying on the patient to provide their own care. But we’re also getting help from their caregivers to do that.
Now, don’t get me wrong, I have many patients who are over the age of 80 or 90 who will show up to their appointments in time, all by themselves. They’re not geriatric patients, but they’re older adults. And I will have patients who will tell me, “Oh, I use an electric toothbrush. I floss twice a day, and they have pristine oral health.” And that’s not very uncommon, too. So you kind of have to gauge where your patient falls on the scale and then repeat home care instructions for them accordingly.
Chuck Cohen: Well, we’re in the middle of a big debate in the United States about Medicare for dentists. Medicare for dentistry, which would address, I assume, some of the issues around senior dental care. So would you like to weigh in?
As we film this podcast, we’re in the debate stage where Congress is considering expanding Medicare benefits that would include dental care. None of that has been decided yet. Dr. Kady, any thoughts on that?
Dr. Kady Rawal: Here are my personal thoughts: it’s great that the American Dental Association started the petition and supported the inclusion of dental benefits within the Medicare plan, but the American Dental Association, as well as the Special Care Dentistry Association, wanted it to go a certain way, which I can appreciate and I can see because these associations have large teams of policy workers and a lot of experienced dentists who have treated the older adult population creating these plans for them.
They also want to make sure that the way the plan is created, the way the dental benefits are provided, helps to reimburse dentists as much as dentists deserve. As I very well said, it takes a lot more time to treat an older adult than it does to treat a healthy young adult. But also, the way the dental benefits should be included in Medicare should benefit public health, should improve access to care for older adults, should give them freedom of choice as to which dentist they want to go to, should make these dental appointments available in their neighborhood, removing access to care barriers.
One of the main things that we see in geriatrics is unaddressed oral health concerns. And so, expansion within Medicare is excellent. We’ve all been, at least in our field of geriatrics… We’ve been waiting for it with bated breath, so we’re very happy to see it happen. But I hope that it happens a certain way that helps public health and these older adults, making dental care not only accessible but also affordable. And it encourages other dentists, whether young, old, or new grads, to accept these older adults.
I told you earlier on in the podcast that I hope that the way the Medicare plan comes about that it motivates dentists to accept older adults in their practice and doesn’t create new barriers for dentists.
Chuck Cohen: I can’t agree more. To add a benefit but make it difficult for those who get the benefit to get the care they’re entitled to is just like a bait and switch. It’s just not productive, so I think there are many details to be worked out along the way. So, I think that what you said, I think, will be generally agreed to within the dental community. We’ll see how Washington does with the topic.
I’d like to switch gears and ask a few questions about your career. And the first one is, and it’s a good segue way from the conversation we just had about public health: you’ve decided to make your career in the public health sector instead of private practice all the time. Talk to us a little bit about that decision and how you came about it. When you look back, do you say, “Wow, I’m really glad I did that,” or do you have some regrets over not doing a private practice?
Dr. Kady Rawal: Actually, none whatsoever. In fact, I’m such a big proponent of hospital practice, as well as public health practice, that every time I talk to students, dental students who are deciding what to do with their lives, I push for it, even though some of them might say, “why not private practice? Why are we doing this?”
And nothing against private practices, of course. I have some very enthusiastic and very successful friends who’ve done very well in private practice. And also, a lot of them see a whole ton of older adult patients, which I’m very proud of. But the reason I chose public health is that I was always inclined towards academia.
What public health practice helps me do in this type of hospital setting is it helps me be an academician. It helps me be a clinician. It helps me be a researcher. So I kind of feel very selfishly that I’m not just having a one-on-one impact on just my patients. Still, I can have a larger impact by training the next generation of dentists by publishing and talking a little bit more about geriatrics and public health as a whole.
So, getting that message out there, academia, and this type of hospital setting appointment gives me that flexibility to wear multiple hats and do all of these things. And I think overall; it paints this beautiful picture for me that gives me my ultimate job satisfaction. So this is one of the reasons why, and I may be the odd one here who never really thought of private practice, but I have thoroughly enjoyed it, and I see a long career in academia continuing to follow this path for myself.
Chuck Cohen: Well, I find it very inspiring. I’ve interviewed a few others who have chosen public health or government dentistry or research over a career in private practice, and I think private practice is great as a profession. Certainly, we’re all in favor of that; that’s the profession’s dominant practice delivery care model.
I think we also have to shine some light on those who choose to do the public health route or the research route because we need competent, talented, interested, enthusiastic people to do what you’re doing as well. Otherwise, the profession is never going to move forward.
And what I heard you say before was, in the role you have now, you just feel you have a lot more impact than you would have if you only practiced in a private practice setting. Did I get that right?
Dr. Kady Rawal: I agree. You got it right that it’s not just about impact; it’s also having the flexibility and the time because I know for a fact that a lot of my colleagues and friends who are in private practice would like to do all of these other things. But as you can imagine, being an entrepreneur and managing your business takes up so much of your time that that time is free time for me to end up doing all of these other things.
And not only to harp on about Work-Life Balance and having enough quality time with my family, but this type of care model that I have chosen to follow does also give me a lot more time to spend with family and loved ones and to strike that work-life balance for myself as well.
Chuck Cohen: That’s great. One more question, then we’ll close it off. You talked before about your parents inspiring you to pursue a career in medicine and dentistry, and dentistry certainly is a branch of medicine. Who inspires you today. Who? Who do you look out there, and you say, “Wow, I’m inspired to go to work, to do what I do every day?” Talk a little bit about that for a minute, if you would.
Dr. Kady Rawal: So, there are so many mentors in my field. I would like to mention Dr. Joseph Calabrese, the director of Geriatric Dental Medicine at Boston University. I remember I was in residency, and I came for my geriatric rotation. I was absolutely in awe of how it’s being practiced and the setting in the long-term care community. As I told you, that was one of my main reasons to move countries and move to the United States.
It’s a very funny incident. When I finished my rotation, I looked at him, saying that when I graduate from my residency program, I would love to have a job here. And he looked at me and said, “No, there’s one job, and that job’s mine.” He has a great sense of humor.
As I came closer to graduating from a residency program, lo and behold, he came looking for me and drew up a contract for me to start working the minute I graduated at the long-term care facility. So, he’s one of my mentors.
I also look up to the growing number of women dental deans, which has taken a long time in the United States for women dentists to be promoted to and be given that responsibility of becoming deans. I think it was a long time coming, and I’ve heard and read so many of their stories and both ADA and ADEA including Dr. O’Loughlin’s story about her journey into becoming a professional leader as a woman. So I know, as women, and especially those of us who are coming from extremely diverse backgrounds, it’s a constant struggle.
Reading their stories and how they have achieved their goals and aims, and how much hard work and constant fighting and that passion it takes to do that as women of color, it’s very inspiring. And so I constantly look up to them, and I hope someday, there are big things in store for me throughout my professional path as well.
Chuck Cohen: I do not doubt that there will be, and there already are. At such a young age, you’ve accomplished so much: Lucy Hobbs Award winner, professor at two different dental schools, your pioneering work in geriatric dental medicine. It’s just been inspiring to watch, and I’ve met you a few times, and we’ve talked, and thank you very much for spending the time with us today.
Hopefully, we’ll have more people tell us, you know, “listen to this” and be inspired to pursue a career that’s similar to yours in geriatric dental medicine or in anything that’s in public health or professional research. All those things are terrific in dentistry.
So, Dr. Kady, thank you very much for spending the time today. This closes another episode of our Driving Dentistry Forward podcast. Dr. Kady, thanks again, everybody. Have a great day.
Dr. Kady Rawal: Thank you so much for having me. Have a great day.