Dentistry and the Poor: The Importance of Access – September 27, 2007
This year's meeting of the American College of Dentists is devoted to a celebration of leadership in dentistry. This is timely, because even though the profession is thriving, we need strong leadership more than ever.
Today, applications to dental schools are soaring. Dentists are busier than ever. More and more research is highlighting the relationship of oral health to overall health, research that only cements the status of dentists as valuable contributors to society.
But this golden era obscures a continuing weakness.
Poor Americans – especially, and unfortunately, underprivileged children – still have poor dental health and experience great difficulty getting dental care. In this time of our greatest strength, we are failing to serve our weakest.
The reasons for these circumstances are complex and arise out of decades of policy and practice. Each day, more and more Americans go from working class to working poor. And, when they pass the threshold out of full employment, health benefits are the first to go. With no healthcare, seeking treatment for oral conditions comes completely off the list.
I know the American College of Dentists has raised professional standards, improved dental education and championed strong ethics. To longstanding members and to those we welcome in today's convocation, I say we must redouble our efforts at improving access to dental care for all – especially all children. I believe this goal goes to the heart of what leadership in dentistry means today.
I have three points for you.
My first is, we know poor children suffer from poor dental health and poor dental care, and we know how to maintain good oral health. Second, while working towards that goal is worthwhile in itself, it will also help our profession. Last, dentists have a history of innovation and leadership in public health, one that suggests we can also make a difference in this area.
I was very disturbed in February by news of the death of Deamonte Driver, a 12-year-old Maryland boy. Deamonte, one of five brothers in a homeless family, died after an infection from an abscessed tooth spread to his brain. Deamonte's story is complicated, and I will get into it in a moment. Let me say for now: What's surprising about this young man's death is not that it happened, but that it doesn't happen more often.
Tooth decay remains the most common childhood disease in America, affecting 59 percent of children. Yet poor children suffer twice as much decay as their better-off peers. The very young and minorities are most at risk. Nearly 30 percent of poor pre-school children have untreated cavities, compared to six percent of the general preschool population. We know how to prevent most dental carries and how to treat them. This is old school, basic, Dentistry 101. Yet, today in America, more than two out of five poor black children and poor Mexican-American children live with untreated cavities.
Despite dramatic improvements in oral health nationally in the past half century, there are a few signs the situation is not improving. The Centers for Disease Control recently noted a 15 percent increase in cavities among children aged 2-5.
It goes without saying, poor oral health has staggering human and economic costs. Imagine trying to concentrate in class while coping with a constant toothache. Think about the growing evidence that oral health is connected to systemic health. Also, consider the medical costs of leaving dental problems untreated until they become emergencies. In Deamonte's case, the cost of just two of his six weeks in the hospital easily topped $200,000.
So, we know we have a big a problem when it comes to poor children's dental health. What's frustrating is, we also know what needs to be done to put a healthy smile on these children. One obvious, yet essential, step is better promotion of preventive oral health.
It's bizarre that, with the benefits of water fluoridation carved in stone, 35 percent of Americans still do not have adequate fluoridated water. The CDC says water fluoridation can reduce the amount of decay in children's teeth by as much as 60 percent. Yet, in California alone, such communities as San Jose, Fresno and Riverside do not have fluoridated water. Too few people understand that dental carries are caused by transmissible bacteria. And, too few people know about simple preventative steps such as using fluorides, brushing and flossing.
Dental sealants are another untapped preventive tool, one especially effective for high-risk or rural kids who rely on well water. Dentists have an illustrious history of advocating preventive care – one more impressive, it can be argued, than medical doctors.
We must build on this tradition of prevention with poor children in our sights. We also need more dentists to see and care for children, especially those in vulnerable situations or communities.
I know many dentists routinely provide unpaid or low-paid assistance to needy patients. A 2000 American Dental Association survey found nearly three quarters of the nation's dentists provide free or reduced-rate services to needy patients. I also know that organized dentistry has effective volunteer programs like the ADA's national "Give Kids A Smile" program.
University dental clinics, including clinics operated by the University of Florida, also offer a valuable safety net to many poor families. More than that, they allow us to connect research and innovation to patients. The Center to Address Disparities in Children's Oral Health here at the University of California, San Francisco is a great example of how academic dentistry can be part of the solution to this problem.
All that said, poor children should not have to depend on charity, volunteerism or universities for basic care. Many of the country's poorest children, about 22 million, are on Medicaid. In theory, Medicaid includes dental benefits. But in practice only about 30 percent of Medicaid children receive dental services. There are several reasons, but one is, too few dentists treat Medicaid patients.
This came through in shocking detail in Deamonte's case. Deamonte's family was enrolled in Maryland's Medicaid HealthChoice Program. The family's ordeal began not with Deamonte but with his 10-year-old brother, DaShawn, whose teeth were in even worse shape. The boys' mother and an assortment of health care workers and legal advocates tried for days to find a Medicaid dentist who would see DaShawn.
Public Justice Center attorney Laurie Norris told a Congressional subcommittee in hearings this spring: "It took the combined efforts of one mother, one lawyer, one helpline supervisor and three health care case management professionals to make a dental appointment for a single Medicaid-insured child!" It was during this struggle that Deamonte began experiencing severe headaches. He had a tooth extraction but was eventually diagnosed with a brain infection. He died Feb. 25th this year.
We all know that dentists limit patients with Medicaid coverage because, in most states, Medicaid reimbursement rates either don't cover dentists' operating costs or provide only a pittance beyond cost. And, dealing with the state Medicaid billing bureaucracy too often represents a monstrous ordeal. I do not think the solution is for us to endure this situation and sign up anyway. Rather, I think dentists should devote themselves and their powerful lobbying organizations to pushing for increased reimbursement rates and streamlined programs tailored to dentists' unique needs.
The evidence is, the higher the rates, the better managed the Medicaid programs, the more dentists participate. Studies show that Michigan and other states have seen large increases in dentists' participation after raising reimbursements. For those of us who live elsewhere, we should be nothing less than outraged that more public dollars are not set aside for this essential care for the poorest of poor children. And, we should let our representatives know.
There is a lawsuit in Florida, my home state, to force the state to increase Medicaid reimbursements. Dentists should lead these kinds of efforts. We should also all make our voices heard in support of proposed federal legislation that goes a long way to addressing the problems I have outlined. Current bills deserving our support include the Dental Health Improvement Act, Deamonte's Law, and especially the Children's Dental Health Improvement Act of 2007.
We can lend a hand in many other ways. We don't have enough pediatric dentists. And, we don't have enough general practitioners dedicated to dealing with the needs of publicly funded and special needs children. The Bureau of Health Professions says at least 31 million people in this country live in underserved areas. I am well aware of the need to carefully monitor the number of practicing dentists in this country.
I understand that dentistry is uniquely vulnerable to oversupply because people often pay for dental services out of pocket. I also know that dentists are independent business people who cope with high overhead, and for many years at the start of their careers, student loan debt that averages well over $100,000.
All that being the case, it is time to think more seriously about opening the doors to more dentists, particularly if we can tie loan repayment programs, tax credits or other incentives to working in areas with shortages and health disparities.
One thing is certain: With under five percent of practicing dentists African-American or Hispanic, we desperately need more minority dentists. If we are to expect to see a diversity of patients, we must have a diversity of practitioners.
This gets me to my second point: If we don't figure out how to serve poor children better, someone else will, threatening our franchise in the process. An increasing number of states are allowing physicians to provide oral health services to very young children, and to be reimbursed by Medicaid and others.
Indeed, the American Academy of Pediatrics lists oral health as a top priority. A number of states have begun to open the doors to dental hygienists working unsupervised by practicing dentists. Meanwhile, due to the shortage of dentists, California is now allowing dentists licensed in Mexico to practice in the Golden State.
One can only imagine the complications that arise in terms of uniform educational preparation, standards of care and the profession's commitment to protect and serve the public. There is no substitute for paying attention to these issues to preserve our autonomy. Added to these challenges, there is a misperception that dentists are more businesspeople than they are healers. Being more receptive to the needs of the poor, and being perceived as such, will help paint a more accurate picture of dentists as the caring and giving professionals we are.
With no end in sight in the debate over health care in America, some may question whether dentists can effect the kind of positive change I have talked about. I believe the answer is yes.
This gets me to my third and final point. We have set the standard for medicine before, and we can do it again. For example, it was a dentist, Horace Wells, who discovered and promoted the world's first anesthesia. And, as I've mentioned, numerous dentists fought long and hard for fluoridation. We can honor these and other advocates by tackling this access to care challenge head on.
Some of us already are.
I want to close with a few details about a dentist who has made a huge difference in his home of Ohio. He is Jack Whittaker, a pediatric dentist in Bowling Green, celebrated in the book, "Dentists Who Care: Inspiring Stories of Professional Commitment."
From the start of his practice, Jack treated Medicaid patients based only on his conviction that it was the right thing to do. After a time, these patients – who journeyed from dozens of miles to see him because they had no other options – sometimes accounted for as much as half his practice. Jack became frustrated with Medicaid and Ohio's low reimbursement rates, so he took action. He lobbied policy makers and lawmakers, eventually convincing a powerful representative to back his cause.
The result was, instead of being paid 35 percent of their customary fees for Medicaid children, Ohio dentists began to be paid 50 to 60 percent of those fees. Jack couldn't solve this problem, but he did what he could while maintaining his practice, and he wound up changing the system.
To me, that's an example of leadership we can follow. Our children, and the dentists who take our place, will be the better for it.
Thank you.
Bernie Machen