Structural Cavities in Rural Dental Health

On the whole, the nation's oral health has improved dramatically, but a shortage of dentists, lack of fluoridation, and poverty have put rural citizens at a dental disadvantage.

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In 2000, the federal government issued the first-ever Surgeon General’s report on Oral Health, emphasizing disparities across the nation. It warned that dental disease in the U.S. constituted a “silent epidemic” with profound consequences for “affected populations.”

In rural America, the “silent” epidemic is in fact strident. In February of this year, The Pew Center for the States issued new evidence that poor dental health is especially severe among rural children and adults. The Pew Center’s Dental Health Campaign reports:

•    Total tooth loss among seniors increases as the population becomes more rural.
•    Rural residents are more likely to have lost all of their teeth as compared to their non-rural counterparts.
•    Rural adults are significantly more likely than non-rural adults to have untreated dental decay (32.6 percent compared to 25.7 percent).
•    In 2001, 67.1 percent of urban residents had visited the dentist in the past year as compared to 58.3 percent in rural areas.
•    The likelihood that a child will be insured for dental work declines steadily as the county of residence becomes more rural

A Remote Area Volunteer Medical Corps dentist treats a patient in Plaquemines Parish, Louisiana, 2012.

The outpouring of patients availing themselves of the Remote Area Medical Volunteer Corps (RAM) , which provides free medical and dental care, offers an unvarnished view of the dental needs in rural America. In October 2011, RAM visited Grundy, Virginia in rural southwest Virginia.  By 5 AM, hundreds stood in the freezing rain to see a dentist.  By the end of the weekend 900 teeth had been pulled.  In 2012, 17 such clinics are already planned by RAM, with similar numbers expected.

Why the discrepancies between rural and the rest of the nation?  The national media has tended to focus on emotional and superficial commentary related to soft drink consumption, and to an extent the images they project and the stories they tell are embedded in tragic fact.  But the whole nation is hooked on syrupy, caffeine-laced empty calories.  Although not always as visible, there are structural issues at work that explain a lot.

Access to Dental Care

There is a severe shortage of dentists in many rural areas.  The U.S. Department of Health and Human Services reports that at the end of 2011 there were 4,670 dental Health Professional Shortage Areas in the U.S.  Sixty-five percent of those were in non-metropolitan areas. Without strong incentives to bring dentists to rural communities, this situation may only get worse.  Nationally, rural areas had a higher percentage of general dentists age 56 or older than did urban areas (42% vs. 38%). In remote locations, 44%of dentists are age 56 or older.

Rural Assistance Center
This map prepared by the Health Resources and Services Administration shows where the the highest priorities are for placing dental professionals. The darker the county, the greater the need for more dentists and hygienists.

Affordability

The number of dental graduates has declined over the last 30 years while the nation’s population has expanded by about 1/3. When supply decreases or demand increases, prices rise. When both happen at the same time, prices rise abruptly.

In many areas it’s difficult to find dentists willing to treat Medicaid patients. Because of low reimbursement rates, paperwork burdens and the perception of a higher percentage of missed appointments, only 1 in 5 dentists accepts Medicaid or State Children’s Health Insurance Program (SCHIP) patients; many such patients are rural residents. In 2008 a Congressional Subcommittee reported that 37% of children in Medicaid ages 2 through 18 received dental care. These rates are far below the Department of Health and Human Services’ target for low-income children’s preventive dental care: 66 percent.

Dental Insurance

Rural children are less likely than urban children to be covered by dental insurance, and children who lack dental insurance are markedly less likely to have made an annual dental visit.  Additionally, insurance reimbursement rates – both public and private—for dental procedures are typically lower in rural areas even though the costs of providing services are often higher in rural areas.  

Fluoridation

The CDC has identified community water fluoridation as one of the 10 great public health achievements of the 20th Century and a major contributor to the dramatic decline in tooth decay.  The American Dental Association (ADA) reports that every dollar spent on fluoridation saves $38 in dental procedures.

Rural residents are less likely than urban dwellers to have access to fluoridated water. Sixty-seven percent of the nation’s population is currently served by fluoridated water systems, but fewer small town water systems are fluoridated. Perhaps this is because water fluoridation is six times more costly per person in communities with fewer than 5,000 people than for water systems serving more than 20,000, according to the CDC.  And, of course, few of the forty million Americans who get their drinking water from private wells drink fluoridated water.

New Directions

The good news is that these problems are fixable.  The bad news is we’re not likely to see significant progress on these issues anytime soon.  Despite the Surgeon General’s trumpeting the “silent epidemic” a dozen years ago, the nation’s dental maladies remain relatively unnoticed, perhaps because they represent less than 5% of health care spending, while the more expensive health problems command attention. Should policymakers find the political will to move forward on these issues, though, there is already widespread agreement among government agencies, associations of health professionals, foundations, and NGO’s on solutions.

The most fundamentally effective and least expensive step –no federal policy required — is early intervention.  The ADA recommends toothbrushing as soon as a child has its first tooth. No toothpaste is needed until age two.  As important as cleaning teeth is feeding teeth. Children should eat more fruits and vegetables and avoid sugary drinks. 

Many worthy policy ideas are being articulated to improve dental health and access to care. Here are four approaches that appear with regularity and stand out for their potential.

Ohio Department of Health
Ohio’s dental sealant program, in operation since the mid-1980s, serves low-income schools in most of the state.
School-based or school-linked sealant programs: Sealants cost 1/3 of what a filling costs, and they don’t have to be applied by dentists. Since poor children suffer twice as much untreated tooth decay as their more prosperous peers, sealant programs targeted to schools with high risk children have proven cost-effective. Despite evidence that these programs can produce intended results and are relatively inexpensive, Pew found that only 17 states have sealant programs that reach even one-quarter of their high-risk schools; 11 states reported having no programs at all.  Ohio’s sealant program has been praised by the CDC.  Because poor children have little access to dental care, some pediatricians are also learning how to apply fluoride varnish on baby teeth, a simple procedure that can prevent cavities.

Fluoridation:   As of 2009, there were 25 states providing less than 75% of their population (the national goal) with fluoridated water. Water fluoridation laws are set at state and local levels, and only 12 states and the District of Columbia have mandatory fluoridation laws.  In areas lacking mandates, technical and financial assistance are advisable to small towns to help fluoridate water systems.
  
Increase government payments for dentistry: States are currently required to provide all medically needed dental services for Medicaid-enrolled children and emergency dental services only for adults. Dental services are not covered under Medicare.  With only 1 in 4 dentists nationally accepting Medicaid enrolled patients, the poor and elderly are at huge disadvantages. Low-income adults and seniors would be well-served if Medicare covered dental services and if Medicaid provided preventive dentistry and included transportation as an ancillary service. It is widely recognized that raising reimbursement rates and reducing administrative procedures for dentists who, in general, have higher overhead costs than other medical providers, will be necessary to convince more dentists to accept Medicaid patients. When Tennessee and Alabama raised reimbursement and altered administrative procedures in the late 1990s and early 2000s, the number of children receiving dental services doubled in just 4 years.
 
Innovative workforce models:  A growing number of states are exploring ways to
expand the types of skilled professionals who can provide high-quality dental health care to children.  Washington state and North Carolina have pioneered projects that set the standard for training and paying physicians, nurses, and medical staff to provide preventive care to very young children. Thirty-five states now reimburse for these services through Medicaid. Dental hygienists are the primary providers in school-based sealant programs in most states, but state laws vary in how they govern this work and many state laws need to be changed. 

4th year students hygienists from Southern Illinois University/Carbondale apply dental sealants on a patient. New programs that would permit non-dentists to practice some oral health care show promise for rural areas but have generally been opposed by the ADA.
One of the most innovative developments — and most controversial from the viewpoint of the American Dental Association — has been the creation of a new position: Dental Health Aide Therapist. The dental therapist is trained to provide basic restorative and preventive services, including fillings and extractions.  Advocates say that dental therapists will help people who can’t afford what dentists charge or who live in remote areas where no dentists have offices. The ADA argues that only dentists are qualified to extract or prepare teeth.  It should be noted that the Dental Health Aide Therapist position is modeled after a program begun in New Zealand in 1921 and now operates in over 50 countries.

The first experiment with using a dental therapists program in the United States was launched in Alaska in 2003 under the authority of the Alaska Native Tribal Health Consortium, a nonprofit health organization owned and managed by Alaska Native tribal governments and their regional health organizations.  The ADA unanimously passed a resolution supporting litigation, should it become necessary, to oppose dental therapists practicing in the Tribal health care system in Alaska. The  dentistry board also authorized an advertising campaign up to a $150,000 level “to educate Alaskan natives and others about the risks of allowing non-dentists to perform irreversible procedures.” In June 2007, a Superior Court judge for the State of Alaska ruled that Dental Health Aide Therapists have the right to provide dental treatment to Alaska Natives, including preventive and restorative care. The ADA dropped its lawsuit but continues to oppose the use of Dental Health Aides in restorative care.

Currently there are programs utilizing dental therapists only in Alaska and Minnesota. Oregon passed a bill last year that allows for a pilot program, and while planning is underway, the program has not yet begun. There is legislation to create dental therapist programs pending in Washington, Vermont, Kansas, New Hampshire, Maine, and California.

Daily Yonder
Thirty years ago, 40% of Americans over age 65 had none of their own teeth. Today, it’s 25%.
On average, Americans have seen significant improvements in oral health over the last 50 years but averages include all conditions along a continuum.  If we look at the continuum closely, we can begin to recognize gaps in health and well-being: low-income and rural citizens have less health insurance, are less likely to have flouridated water, receive less dental health care and experience more dental decay and tooth loss.

Dental costs amount to a small percentage of medical costs overall, but failure to deal with them can lead to serious — and very expensive — problems. It’s evident by now that private dental practice is not always financially viable in rural areas. This means that the dental health of rural Americans will have to be addressed by government or philanthropic forces. Even as extending medical care to the uninsured remains a contentious issue, is the nation ready to listen up and heal the “silent epidemic”?

 

 

Topics: Health
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