Where are the Dentists?
Author: Dianna Gordon, NCSL
There's a lot of pain. There's a lot of disfigurement. People can't even get jobs if they have bad teeth. No one is going to hire a person who has to hold a hand over their mouth when they talk because their teeth are so bad." So speaks Marcia Brand of the federal Health Resources and Services Administration, Office of Rural Health Policy.
And West Virginia Delegate Barbara Evans Fleischauer concurs. "During our evaluation of welfare reform, we asked people who had difficulties getting jobs why they had problems. Twenty-one percent said it was because of their teeth. I thought it was heartbreaking, a sad problem and one people don't seem to take very seriously."
It has been called the "silent epidemic." And as the nation struggles with threats of terrorism and war, a poor economy, and continuously rising health care costs and insurance rates -- improved oral health seems to have been left by the wayside. "People seem to think oral health--nice, shiny white teeth--is a luxury. It's not. We need to make it a national priority," Brand says.
Rotten teeth have taken a backseat to other national health and economic concerns, especially in rural areas where family dentists are few and far between. But the price is troubling:
In rural areas, the lack is especially evident. Children, adults and elders with bad teeth face special challenges to better health -- lack of dentists, an even lower number of dentists who accept Medicaid or other discounted fees and reluctance by dentists to participate in managed care programs. The patients themselves also experience other barriers to good care since rural populations tend to be marked by poverty, limited education, cultural differences, lack of transportation and the absence of any kind of coordinated screening and referral processes.
PROBLEM: BAD TEETH; SOLUTION: EARLY PREVENTIVE MEASURES
Perhaps two of the easiest and most cost effective solutions to today's dental crisis are preventive: fluoridation of community water supplies and sealant programs.
Researchers discovered as early as the 1930s that people living with naturally fluoridated water had fewer cavities. Today, water fluoridation costs less than $1 per person per year. And it's estimated that every dollar spent on supplementing drinking water with fluoride averts $38 in dental care, according to the Journal of Public Health Dentistry.
More than 100 million Americans do not drink fluoridated water. In fact, San Diego, San Jose, Wichita, Portland, Ore.; and Honolulu are among the large cities that do not provide fluoridated water. (Note: California passed a law in 1995 to fluoridate water in large cities, so San Diego and San Jose have been proceeding to fluoridate). Fewer than 25 percent of the water systems in Utah, Hawaii, New Jersey, and Montana are fluoridated, with California, Wyoming, New Hampshire, Idaho and Mississippi water supplies only 25 percent to 50 percent fluoridated. Community water fluoridation has its opponents. A variety of groups, such as the Fluoride Action Network, Citizens for Safe Drinking Water and the Citizens for Health, oppose fluoridation because they claim it has never been tested for safety; it leads to a high incidence of fluorosis (discoloring of tooth enamel); and causes health problems such as bone fractures, cancer, and osteoporosis.
Dental sealants also are another low-cost, effective way to prevent cavities in children's teeth. Plastic material applied to the teeth, sealants form a hard, protective coating that guards against decay. Unfortunately, only 3 percent of low-income children under 8, and less than 25 percent of children overall, have received dental sealants.
The Centers for Disease Control and Prevention (CDC) has offered grants for coordinated school health programs to encourage states to increase use of dental sealants. The Wisconsin Department of Health and Family Services has established the Seal A Smile initiative, which made available $60,000 in state money for sealant projects. The nonprofit groups Oral Health America and America's Promise are dedicated to improving oral health for America's children, and have partnered to provide a million dental sealants to approximately 225,000 children by 2010.
PROBLEM: LACK OF DENTISTS
One of the main reasons Medicaid patients don't receive necessary dental care is because there are few dentists participating, according to Dr. Steven Steed, Utah dental director. And dentists don't participate because of low reimbursement rates, difficulty in administration and patients failing to keep appointments (the national failure rate is approximately 30 to 50 percent).
Five years ago, Utah set out to change those patterns:
The rate hike initially resulted in some increases in the number of Medicaid dental providers and improved access to care -- especially in rural areas. Urban providers who treated more than 50 Medicaid patients increased.
In its Oral Health Improvement Act, the Utah Legislature also established an early intervention, prevention and awareness program and set up a case management program to help Medicaid clients.
Aging practitioners is another problem. In a survey of Alabama, California, Maine, Missouri and Montana, Professor Gary Hart, director of the Rural Health Resource Center, University of Washington, found a "significant" shortage of dentists in rural areas. And it will get worse. Hart discovered that rural dentists are older and plan to retire. There's also a shortage of hygienists.
Aging dentists are not just a rural problem. Thirty-five percent of all dentists are over age 55. By 2014, the number retiring will exceed those entering the field.
PROBLEM: GEOGRAPHIC ISOLATION
When people say "rural" one of the sights brought to mind is charming little villages nestled among rolling hills. What is not immediately apparent are the sheer distances people must travel for the staples of life, including medical and dental care.
In response to these needs, states have literally put dental offices on wheels, moving mobile units across the rural landscape. These programs include the national Smiles Across America, sponsored by the nonprofit Oral Health America organization; Healthy Kids and Seniors, Phoenix; Miles for Smiles, Colorado, Nevada and Maine; and Miles of Smiles, Illinois.
These mobile clinics offer school-based preventive care, including sealants. Staff also visit nursing homes and assisted living communities, as well as the homebound and disabled.
Diane Brunson, Colorado dental director, notes that such traveling units provide services to children who might otherwise never see a dentist, and they raise awareness of oral health.
The down sides are the difficulty in finding "mobile" dentists; providing emergency care; getting the community to buy in to the program; funding; and finding storage space for mobile units when not in use.
Despite sometimes unique and difficult logistics of such a nomadic lifestyle for staff -- the units need 50 amp connectors requiring communities to spend up to $2,000 for installation and disposing of all the water used at the dental facility) -- Colorado Miles for Smiles served 5,438 patients between August 1999 and June 2003. That was 605 days of patient care for people who may not otherwise have been able to see a dentist. Washington Smile Savers has six units serving 30,000 patients a year.
OTHER THINGS STATES ARE DOING
Brand emphasizes that though there is federal help by way of grants and research funding, "there is enormous demand. The solution lies in the states, and they have been extraordinary in addressing the issue."
Delegate Fleischauer says that by combining State Children's Health Insurance Program(SCHIP) and Medicaid money, "every state should be able to help kids from birth and help raise a generation that is cavity-free."
In fact, West Virginia instituted a pediatric screening program at each of its community health centers that screens newborns to 2-year-olds for "early oral health intervention," Fleischauer says.
"We have dentists at each community health center and we have doctors cooperating with them," she says. "And they've actually trained several hundred people to help patients improve their oral health. It's a unique pilot project and has a lot of potential."
Other state activities include:
WHAT STATES CAN DO
Obviously, the news about rural dental care is far from rosy. But there are other things state and local policymakers can consider, including using loan repayment programs for rural dentists and hygienists and exempting volunteer dentists from liability for work in mobile, community or rural health centers.
Policymakers also can work with rural high schools and colleges to recruit new dental students and establish scholarships. Besides adding dental services to rural and community health centers, revolving loan funds can be started for rural practices, as well as grants for equipment upgrades. And high tech can be added to the mix. "Teledentistry" via e-mail or video can save trips by patients and mobile units. All in all, providing the means for good oral health in rural areas can prove difficult, but there are solutions for states and communities to consider.
Contributions to this article were also made by Stephanie Wasserman, Shelly Gehshan, and Allison Cook.
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