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Inside Dentistry

April 2006, Volume 2, Issue 3
Published by AEGIS Communications


Access to Care

Lisa Neuman; Lesley Ranft

Who Gets It… and who Doesn’t

Providing better access to care can offer endless possibilities but, without the help of those in a position to affect change, it may be the dental profession’s most challenging problem.

For many Americans, “access to care” is something taken for granted. Living in the most industrialized nation on the planet perhaps gives us all a false sense of security when it comes to our healthcare—we have the best medical schools, the best hospitals, the best specialists, and the best medical technology in the world. But the best medicine will not work when it cannot be accessed. For the millions of Americans living in fear of illness or accidents because they have no health insurance, the harsh reality is they are shut out of the healthcare system entirely, and for many this literally means the difference between life and death.

And it is not just the medical healthcare system, either. The same issues are also haunting the dental healthcare system. In fact, the access to care problem is even worse in dentistry: in 2000, the US Department of Health and Human Services published Oral Health in America: A Report of the Surgeon General,1 which found that 108 million children and adults in the United States had no dental insurance—twice the number of Americans who had no medical insurance. In 2002, an update to the Report2 found that dental caries was the most chronic childhood disease—5 times more prevalent than asthma and 7 times more common than respiratory allergies such as hay fever. Last year, the Centers for Disease Control and Prevention (CDC)3 further supported those statistics when it found that preventable tooth decay is one of the most chronic childhood diseases among children aged 5 through 17. In 2004, the World Health Organization4 reported findings on caries prevalence in 12-year-olds worldwide with startling results for the United States: while 1.75% percentof American 12-year-olds were found to be affected by decayed, missing, and/or filled teeth (DMFT), the overall global average of 12-year-olds with DMFT was only 1.61%.

These reports, taken together withthe number of Americans who are uninsured/underinsured and/or under educated about dental healthcare, paint a bleak picture for the oral health of America in 2006. It is a picture that many dental healthcare experts want redrawn to show easy, effective, and affordable access to dental healthcare for America’s children, elderly, disabled, and poor.

There is good news: Support from nonprofit organizations is increasing, leaders who can help meet the objectives to improve access to care are stepping up, and consumer awareness appears to be rising. However, there are large and numerous challenges that still must be addressed and overcome before the nation’s access to care problem is solved, and it is very much up to the dental healthcare community to take an active role in identifying the problems and creating the solutions.

The Consumer Awareness Aspect

Perhaps one of the most specific problems—and one of the most difficult to overcome—with individuals and groups at high risk for dental diseases is that many do not seem to be aware that they are at high risk. The elderly may assume their teeth are supposed to fall out as they get older. Parents may not recognize the importance of caring for their children’s primary teeth because most of those teeth will be gone by the time the child goes to kindergarten. Many people may not realize the impact of high sugar consumption and overall poor nutrition on oral health regardless of their income and education level, although dietary risk factors do seem to be more prevalent in lower-income populations.

Despite the growing body of evidence linking oral and systemic health, there is still an alarming lack of oral health awareness among healthcare providers, due in large part to a failure to educate these professionals on the potential impact of poor oral health on conditions such as heart disease and adverse pregnancy outcomes. As Liz Rogers, director of communications for Oral Health America, explains, “The importance of oral health in relation to total health has been overlooked. While many states are working to come up with better plans and practices to serve the needs of the underprivileged, there is a general lack of awareness when it comes to the impact of oral hygiene on day to day life,” she says. “For example, 51 million school hours are lost due to dental-related problems each year.”

Sadly, but not altogether unexpected, it is the nation’s children that seem to suffer the worst effects from the inadequacies of the dental healthcare system. The Children’s Dental Health Project, a nonprofit policy and analysis organization designed to improve access to oral health for children, has found that between 3 and 4 million of the nation’s children suffer from dysfunctional dental pain. A full 20% of the nation’s preschoolers have had cavities; the figure rises to a staggering 50% by the time they reach second grade.2 Just this past January, the Agency for Healthcare Research and Quality5 reported that approximately 32 million children in the United States do not receive regular dental checkups. It further found that children whose parents are not well educated fare even worse—they were only half as likely to receive regular dental checkups as children whose parents were college educated. As Amid Ismail, a professor in the Department of Cariology, Restorative Sciences, and Endodontics at University of Michigan’s School of Dentistry, explains, “We can’t solve the problem drilling teeth. We have to address the core problems for children, the elderly, and the disabled, including lack of knowledge, diet, hygiene, and high sugar consumption.”

With the probability of children receiving regular dental checkups being associated with such socio-demographic factors as income, ethnicity, and parental education, the overall lack of consumer awareness among the underprivileged has given rise to another disturbing trend: exploitation by unauthorized care providers. Dr. Cherilyn Sheets, founder of the Children’s Dental Center, explains: “There are unlicensed clinics and people serving the needs of the underprivileged, which just highlights the need for providing quality care to this segment of our society. There is a call for action to broaden the scope of services and turn emergency treatment into comprehensive care, including preventive therapies and education reducing the demand for emergency service and solving the access to care issue.”

The Demographic Aspect

The Age Issue
As the media have made us all well aware, this country faces a multifaceted problem with the aging of the baby boomers. The first wave of this generation is preparing to retire, which has the potential to cause two significant changes in the nation’s dental healthcare system.

The first change could impact who gives dental healthcare. With large numbers of dental healthcare providers—dentists as well as dental hygienists—retiring over the next 20 years, the possibility exists of shortages in educated, practicing providers to absorb the influx of patients looking for new doctors and dentists. According to an article published last fall in the American Dental Education Association (ADEA)’s Journal of Dental Education,6 enrollment in the nation’s 56 dental schools declined by 25% from 1997 to 2001, but it is now once again on the rise as interest in business careers wanes in the wake of corporate scandals and dentistry reemerges as a healthcare profession vital to overall public health. The article’s authors issue this challenge to take an interest in being agents of positive change: “Resolving issues of equitable access to oral health care is a responsibility and obligation of the whole profession—education, regulatory, and practice communities alike. But the dental schools do control the admissions process and, thereby, have the responsibility to administer and document a fair process that selects a diverse body of capable students, giving rise to competent graduates and practitioners that best serve the public good and the public’s health.”

The second change could impact who receives dental healthcare. According to the 2000 Census, nearly 35 million Americans, or 12.4% of the total US population, were over the age of 65.7 The Centers for Medicare and Medicaid Services reported in 2003 that 35 million Americans older than age 65 were enrolled in the government assistance program; however, only 33 million had full coverage, meaning they were enrolled in both Parts A and B.8 Meanwhile, according to the CDC,9 less than 20% of Americans 75 years of age and older are covered under private dental insurance. The gaps between what Medicare will cover and what private dental insurance will cover can mean that many older Americans are left with no coverage at all. As a result, many of our elderly are relying on Medicaid to pay for their dental healthcare, which is being largely delivered in hospital emergency rooms rather than in dentists’ offices; many dentists choose not participate in the Medicaid program because of low reimbursement rates.

To put this in perspective, Oral Health America recently graded the “state of decay” among older Americans.10 This “report card” showed disturbing results: The final overall grade for the provision of dental healthcare for the nation’s elderly was a “D.” In the most industrialized country in the world, the level of private dental coverage for the elderly was graded a “D,” the level of Medicaid dental coverage was graded a “D+,” Medicaid reimbursement rates received an “F,” and the dental Medicaid program for the elderly overall was graded a “D.”

Without access to regular checkups and preventative oral healthcare, theelderly face the increased likelihood of chronic oral pain resulting from periodontal disease, and in many cases tooth extraction for severe cases of untreated tooth decay. And as they get older, oral health conditions left unchecked and untreated can severely limit their daily activities, affect their nutritional intake, alter their level of independence, and complicate other existing overall health issues. The future outlook looks bleak without legislative change. Robert Lauf, the immediate past chair of the American Dental Association (ADA)’s Council on Access, Prevention, and Interprofessional Affairs, believes that numerous changes need to be made in order to provide elder care in the years to come, including education for allied healthcare professionals (such as nursing home staff members) and grassroots initiatives to petition policymakers to affect change.

The Location Issue
According to the National Association of Counties, of the nation’s 3,067 counties 71%, or 2,187, are classified as rural.11 One of the most economically distressed areas in the United States is the 1,000-mile Appalachia region, encompassing 410 counties in 13 states.12 Extending from southern New York to northern Mississippi, the region is home to more than 23 million people. While there are large urban areas located in metropolitan pockets throughout the region, much of the region is considered extremely rural. Sixty percent of Appalachia’s population live in the metropolitan areas, another 25% live in areas directly surrounding the metropolitan areas, and 15% live in the most remote, rural areas of the region.13

Poverty rates in many areas of the region have decreased substantially over the past several decades, but there are still widespread areas where people live without electricity or running water. In 2003, 121 counties in Appalachia were classified as “economically distressed,” with rates of poverty, unemployment, and underemployment much higher than the national average.13 Many of these counties are located in West Virginia, Kentucky, Tennessee, and Alabama.

As could be expected, significant disparities exist in terms of the health of Appalachia’s population. Mortality rates from the 10 leading causes of premature death—including heart disease and diabetes, for which periodontal disease has been shown to be a risk factor—are excessively higher in Appalachia compared with the rest of the United States.13 And in much of Appalachia, there are considerable barriers to receiving adequate healthcare, including long physical distances to medical resources, rugged terrain, lack of both public and private transportation, lack of health insurance, and, because of lower-than-average wages, a greater likelihood of inability to pay for healthcare services.13 To compound the problem, in many areas of the four most economically distressed states the ratio of primary care providers to patients is as low as 1:4,000.13

According to the CDC’s National Oral Health Surveillance System,14 for West Virginia’s population of 1.8 million people, there are only 761 dentists practicing in the state. In Alabama, there are only 1,909 dentists for a population of 4.5 million. These data mean that even if patients could reach these dentists’ offices and pay for their services, they would still have to wait in line behind more than 2,300 other people, on average.

For many dentists, the idea of practicing in a rural area such as Appalachia is not very enticing. The trend for graduating dentists seems to be to gravitate toward large urban centers and their dense populations in order to get their new practices off the ground and become profitable. To meet the goals of public health initiatives such as Healthy People 2010—which should be considered especially critical to the health and well-being of the underserved populations of Appalachia and other economically depressed areas of the United States—will require both cooperation and compromise between many layers of the public and private sectors.

The Cultural Issue
The multicultural aspect of providing dental healthcare is a multidimensional issue—at the very least comprising differences in expectations, if not in language and prosperity. “It must be recognized that there are differences in treating people of color in order to provide a strong dentist-patient relationship. Serving multicultural needs means that the practice staff members can speak the patient’s native language, knows how to respond to various attitudes regarding treatment for different minorities, as well as the appropriate follow-up considerations for minorities in order to ensure that the treatment plan is complete,” says Sheila L. Thorne, president and CEO of the Multicultural Healthcare Marketing Group, LLC. What is one of her biggest concerns? “Some people believe that the type of insurance card determines the quality of care for a person in the minority population group.” Texas is just one example of the imbalance between minority identification and dental care. Minorities comprise over 65% of Texas’s uninsured, with close to 2 million children on Medicaid, yet only 15% of the nearly 14,000 dentists practicing in the state are enrolled in the Medicaid program.15

According to advocacy group Negative Population Growth, whose mission is to educate the public and political leaders on the detrimental effects of overpopulation on the environment, immigration now accounts for the addition of 1 million people to the US population every year.16 In the 2000 Census, the total foreign-born population had risen 57% from the 1990 Census, accounting for more than 31 million people. In the end, many Americans of minority ethnic backgrounds are less likely to receive dental healthcare and are more likely to be in poor dental health.16

The Affordability Predicament

As the overall availability of dental insurance declines, so does the quality of the coverage remaining—until “discount” or “limited benefit” programs predominate. As Fred Joyal, founder of 1-800 DENTIST and contributor to the National Children’s Dental Foundation explains, “If people do not receive the dental care they need because it is unaffordable, it can become a lifelong problem. Discount programs do not solve the access to care issue. Affordability is still a concern.” Yet, there are positive examples being set by insurance companies, nonprofit organizations, and state government initiatives. For example, Delta Dental set a goal to provide dental insurance programs to more than 25% of the approximately 156 million Americans who do not have dental coverage and is now offering benefits to more than 45 million people in nearly 76,000 groups throughout the United States.

Despite such intiatives, the inability to afford care remains one of the biggest challenges to providing care. As Fern Ingber, executive director for the National Children’s Dental Foundation, explains, “Unless we build a network of reduced-cost dental care centers that can focus on prevention, education, and treatment, we will neglect the needs of millions of children.” We will also neglect the needs of the elderly, the disabled, and the minority populations.

The Medicare/Medicaid Predicament

“The number of people over 65 years of age is increasing dramatically. And although many of tomorrow’s elderly, unlike the elderly of the past, may have invested thousands of dollars in their teeth, they may not be able to maintain their oral health in elder years due to the lack of benefit coverage,” notes Dr. Paul Glassman, associate dean for information and education technology at the University of the Pacific. Under Medicaid, federal mandates provide specific dental benefits to children; however, dental benefits for adults are determined by each state, but whether individual states offer preventative and/or restorative care to its residents is optional. When they are offered, such benefits are only partially funded through a matching federal program. The federal government uses a “Federal Medical Assistance Percentage” formula to determine the amount of the match that should be allocated to each state. Unfortunately, but perhaps not unexpectedly, many states have elected not to participate in providing these “optional” dental healthcare benefits. In 2005, only seven states provided full adult dental healthcare benefits, while the other 43 states elected to provide only emergency treatment or, worse, no benefits at all. To add insult to injury, the reimbursement levels for dental healthcare rendered are particularly low, dissuading many dentists from accepting Medicare and Medicaid recipients. Although some Medicare recipients receive supplemental Medicaid as well, there is still a great number of the elderly with insufficient dental benefits. A particularly egregious example is Louisiana. According to Dr. Michael Helgeson, president of Special Care in Dentistry, “Louisiana provides limited coverage for dentures and no preventative services or treatment plans for infections. However, Louisiana will pay for tooth extractions.” The result? More than 34% of Louisiana’s older population (those aged 65 and over) are completely edentulous.

The Workforce Predicament

The ADA report Future of Dentistry Executive Summary17 states, “Dentistry can be proud of its accomplishments. This nation’s oral healthcare system—encompassing education, research and development, clinical practice and more—is widely regarded as the very best in the world.” But for all of the profession’s accomplishments, much more still needs to be done to address the shortfalls of the dental healthcare workforce. The report further states, “The dental profession must develop a balanced workforce...one that is sufficient in number andeducationally and culturally prepared...to satisfy the needs of the public. The workforce must also be balanced in its capacity to address health promotion and disease prevention as well as diagnosis and treatment for the public it serves.”

One area that demands attention is the limited number of dental schools in the United States. A direct consequence of having so few schools to choose from is the discouragement of potential future dentists to apply to dental school, which in turn has the ripple effect of a limited number of dentists graduating each year who could potentially care for the very people suffering from the lack of access to care. Ronald Ettinger, director of geriatric programs and professor of prosthodontics at the University of Iowa, says that “access to care has become more and more limited due to lack of federal and state funding for programs serving persons on entitlement programs.” For example, Chicago once had three dental schools to educate dentists who could then help serve the needs of the underprivileged. Today, Chicago has only one dental school—in essence comprising the safety net for the city’s underprivileged citizens.

The safety net is compromised in other areas of the profession as well. The dental profession has long worried about the potential shortage of qualified, educated dental healthcare providers looming in the future, once baby-boomer dentists and allied dental healthcare professionals begin to retire. In fact, there is already a shortage of registered dental hygienists although there are more than 120,000 currently practicing in United States, and according to a study reported by the American Dental Hygienists’ Association (ADHA),18 the need for these professionals has been projected to grow more than 35% over the course of this decade alone. However, the Bureau of Labor Statistics indicates that the growth rate for hygienists is much better than that for dentists in the foreseeable future; in fact, the number of dentists is expected to decline as fewer dental students graduate to take the place of retiring dentists, which will in effect slow down the overall growth to just 4%, while the hygiene profession can expect projected growth of 43%, through 2012.18

What can public policy do?
A problem as complex and far-reaching as access to dental healthcare will require the effort and initiative of federal, state, and county governments, public and private sector organizations and foundations, dental and dental hygiene schools, and the dental profession as a whole. “When it comes to public policy and access to care infrastructure, the lack of governmental support for oral health services of vulnerable patients has tied the hands of the dental profession,” says Dr. Greg Folse, national director of governmental relations for Special Care Dentistry. From the low reimbursement levels and limited scope of Medicaid dental services to the lack of cooperation from the federal and state governments to support a safety net, there are many public policy pitfalls.

In fact, recent legislative changes do not yet reflect positive reform for the access to care issue. According to Dr. Burt Edelstein, professor of dentistry and health policy at Columbia University and founding director of the Children’s Dental Health Project, “The federal government’s recent decision to shift authority and responsibility to the states for benefits is a public policy issue that must be furthered addressed in order to ensure ongoing entitlement for children’s dental care.”

The University of Michigan’s Dr. Ismail agrees. “Without compensation to providers for offering care to those without access, we need to find other ways to reduce the burden. It is important to build a network of matching federally funded programs and reduce the cost of operations in rural areas. This will translate into improving access to care.”

The Special Care Dentistry Act
The Social Security Administration uses the terms “aged, blind, and disabled”to identify adults and children at high risk for receiving little or no healthcare. The Special Care Dentistry Act extends required Medicaid dental benefits beyond children to include these vulnerable adults in every state. It does not require coverage for all adult populations, but it does aim to provide efficient and reasonably priced dental healthcare to reduce the pain and suffering of Medicaid enrollees by providing treatment for tooth, gum, and bloodstream infections. The Act addresses disparities in the access to care for these at-risk populations and is designed to reduce avoidable general healthcare costs in three important ways: by expanding federally required Medicaid coverage to include the nation’s aged, blind, and disabled; supporting individual states by increasing federal funding for Medicaid oral healthcare services to a 90%/10% federal-state match; and providing additional support for other medically necessary services such as transportation. Among the supporters of the Special Care Dentistry Act are the ADA, ADHA, ADEA, Academy of General Dentistry, Association of State and Territorial Dental Directors, and the American Association of Public Health Dentistry.19

Calling All Interested Parties
Despite all of the best intentions, access to care initiatives will not succeed without support from all interested—and influential—parties. According to Dr. Thomas Machnowski, president of the Chicago Dental Society, “There needs to be a concerted effort between the nation’s dental organizations, their members, dental companies and manufacturers as well as public policy leaders in order to shift the current state of dental care.” The Chicago Dental Society has done its part by donating $1.85 million to Chicago-area educational institutions and public health programs last year. The society supports two kinds of programs: those that promote the profession of dentistry and those that serve the oral health needs of the public. In addition, the Chicago Dental Society manages a dental supply program that has donated over 100,000 toothbrushes and 100,000 tubes of toothpaste to schools and local community organizations.

The Smiles Across America program is another example of how individuals, industry, and oral health coalitions are coming together to address the access to care problem. The program, which began in 2002, is designed to help expand school-based or school-linked oral health programs for uninsured and underserved children. It is currently up and running in Chicago, Las Vegas, Minneapolis/St. Paul, the Santa Barbara County/Ventura County area in California, and Maine; it is scheduled to expand to West Virginia, New York City, and South Carolina in 2006. “In each location, we have partners who help make the program a success,” says Ms. Rogers of Oral Health America, the major contributor to the success of Smiles Across America. “Often, there are existing oral health coalitions who support school programs, but need help.” The program is financially supported by the Ronald McDonald House Charities, Patterson Dental Foundation, Cadbury Adams (manufacturers of Trident Gum), and a host of local foundations and sponsors in every location. For example, 3M ESPE and DENTSPLY are donating dental sealant materials for the Smile Across America program and for Oral Health America’s National Sealant Alliance, which is committed to sealing 1 million teeth by 2010. Moreover, DNTLworks Equipment Corp. has donated mobile dental equipment to the Smile Across America program.

The good news is that there are many other great examples of association and industry support for access to care—dental manufacturing companies are strongly supporting the cause as well (See So, HowAre the Kids?, page 50). As Robert Hayman, CEO of Discus Dental, explains, “It is critically important for everyone involved in the dental industry to serve the needs of those who require better access to care. The National Children’s Dental Foundation, the first nonprofit organization with the exclusive mission of serving the dental needs of children, is a great way to make a significant impact on the needy children of this nation.”

Conclusion

The dental industry has a prime opportunity to shift the access to care paradigm. The campaign for addressing the issues and solving the problems entails moving the millions of uninsured, underprivileged, and underserved children and adults from triage and emergency care to regular preventative care. Raising consumer awareness to the demographic, economic, cultural, and educational issues also is required if we are to begin filling in the public policy gaps to better reach rural areas, solve the affordability of healthcare issues, and work to reverse and resolve the approaching workforce shortage crisis. Ultimately, however, the most forceful push for access to care reform must come from the dental healthcare providers themselves, who are in the best position to understand the dental healthcare needs of the nation’s growing population and can also see the direct benefit of demonstrating goodwill in our local, as well as our national, communities.

Editor’s Note: The publishers and editors of Inside Dentistry are committed to providing in-depth news and analysis on this topic and to actively participating in the ongoing discussion and dialogue as the dental profession and industry work together toward creating and implementing solutions. To that end, future issues will examine the major contributing factors to access to care in greater individual detail, as well as report on legislative reforms and educational initiatives. The publishers and editors welcome your thoughts, opinions, and reactions to our editorial coverage of this critical aspect of dental healthcare. Please send your letters to letters@insidedentistry.net

REFERENCES
1. United States Department of Health and Human Services. “Oral Health in America: A Report of the Surgeon General.” Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

2. United States Department of Health and Human Services. “Oral Health in America: A Report of the Surgeon General.” Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health, 2002 update.

3. Centers for Disease Control and Prevention. “Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis—United States, 19881994 and 19992002.” Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion; Division of Clinical Research and Health Promotion, National Institute of Dental and Craniofacial Research, National Institutes of Health; Division of Health and Nutrition Examination Survey, National Center for Health Statistics. MMWR Surveillance Summaries. 2005;54(3): 1-44.

4. World Health Organization. WHO Oral Health Country/Area Profile Programme. Geneva, Switzerland. Available at: http://www.whocollab.od.mah.se/countriesalphab.html. Accessed February 18, 2006.

5. United States Department of Health and Human Service. Agency for Healthcare Research/Quality. Child Health Research Findings. Available at: http://www.ahrq.gov/research/childfind/chforal.htm. Accessed February 18, 2006.

6. Weaver RG, Ramanna S, Haden NK, et al. US dental school applicants and enrollees: 2003 and 2004. J Dent Educ. 2005;69(9):1064-1072.

7. US Census Bureau. Table 1Population65 Years and Over, for States and for Puerto Rico: 1990 and 2000. Availableat: http://www.census.gov/population/cen2000/phc-t13/tab01.pdf. Accessed February 18, 2006.

8. US Department of Health and Human Services. The Centers for Medicare and Medicaid Services. Medicare enrollment-aged beneficiaries as of July 2004. Available at: http://www.cms.hhs.gov/MedicareEnRpts/Downloads/04Aged.pdf. Accessed February 18, 2006.

9. Centers for Disease Control and Prevention. “Surveillance for the Use of Preventative Healthcare Services by Older Adults, 1995-1997.” MMWR. 2000; 48(SS08);51-88.

10. Oral Health America Special Grading Project on Older Adults. “A State of Decay: The Oral Health of Older Americans.” September 2003.

11. National Association of Counties. Statement of the Honorable Karen M. Miller, Commissioner, to the US House of Representatives Government Reform Subcommittee on Technology, Information Policy, Intergovernmental Relations, and the Census. April 29, 2003. Available at: http://www.naco.org/Content/ContentGroups/Legislative_Affairs/Advocacy1/Agricultur1/
Testimony_of_Commissioner_Karen_Miller_on_Rural_Grants.htm
. Accessed February 19, 2006.

12. Appalachian Regional Commission. Economic overview. Available at: http://www.arc.gov/index.do?nodeId=26. Accessed February 19, 2006.

13. Appalachian Regional Commission. An analysis of disparities in health status and access to healthcare in the Appalachian region. November 2004. Available at: http://www.arc.gov/index.do?nodeId=2467. Accessed February 19, 2006.

14. Centers for Disease Control and Prevention. National Oral Health Surveillance System. “Synopses of State Dental Public Health Programs, 2004.” Available at: http://www2.cdc.gov/nccdphp/doh/synopses/StateDataV.asp?StateID. Accessed February 19, 2006.

15. The State of Texas Office of Rural Community Affairs. Available at: http://www.orca.state.tx.us. Accessed February 19, 2006

16. Negative Population Growth. Population Facts and Figures. Available at: http://www.npg.org. Accessed February 19, 2006

17. The American Dental Association. “Future of Dentistry Executive Summary.” Available at: http://www.ada.org/prof/resources/topics/futuredent/future_execsum.pdf. Accessed February 19, 2006.

18. The American Dental Hygienists’ Association. “Dental Hygiene: Focus on Advancing the Profession.” Available at: http://www.adha.org/downloads/ADHAFocus_Report.pdf. Accessed February 20, 2006.

19. The American Dental Hygienists’ Association. Governmental Affairs link. Available at: http://www.adha.org/governmental_affairs/news/index.html. Accessed February 20, 2006.

A Renewed Access to Care Campaign

Today the movement for access to care is in the process of reform. Government agencies, professional associations, dental and public health schools, dental manufacturers, and nonprofit organizations are working independently and together to fill the gaps that current public policy leaves behind. Large corporations also have helped to bolster the movement by taking a vested interest, and investing money, in serving the needs of the nation’s underprivileged.

There is much work to be done. But you don’t have to be a member or employee of one of the key players in dental public health reform. There are a number of ways that individual dental healthcare professionals and individual dental practices can help affect change. Here are just a few ideas.


Initiate an oral health public relations and advertising campaign.
The demonstration of a practice’s goodwill toward the oral and overall health and well-being of the community it serves can go a long way in both improving oral health and increasing patient acquisition and retention. Consider participating on local hospital committees and boards. Offer to do a lecture series at a senior citizens center or in the local schools. Create a public relations strategy complete with press releases, public service announcements, advertising, patient seminars, newsletters, and/or a direct mail campaign to get your message out to the community on the importance of good oral health. Seek out and begin positive working relationships with primary care physicians in the community, letting them know your stand on the importance of oral healthcare and access to care issues. Whether you decide to implement a broad educational campaign or focus your efforts on a particular area, such as new mother/infant care, minority group considerations, caring for the elderly or disabled, or addressing the needs of children, your contribution to both your practice and your community can be great and can return great rewards as well.


Take an active role in educating the political leaders and representatives in your community, city, and/or state.
Visit the CDC’s National Oral Health Surveillance System to identify the level of access to care and the critical issues in your state. Consider what contribution you would like to make and contact the programs listed on the site to learn more about how to get involved (http://www.cdc.gov/nohss). Visit the Special Care in Dentistry Association’s advocacy page at http://www.scdonline.org to find a list of supporting organizations, summaries of legislation, and advocacy activities. Contact policymakers in your city, county, and/or state to inform them of your stand on access to care issues. Inform the legislators what actions you want them to support, such as more comprehensive dental education requirements; more consistent credentialing/licensing practices and procedures from state to state; a continuing care agreement with Medicaid to assist with the funding necessary to serve extremely poor and rural areas; or state funding to assist with the operational costs for new rural practices and programs to reach the underserved, to name just a few.


Consider volunteer work.
Considering serving as a provider or consultant in a volunteer capacity with children-oriented programs, such as Women, Infants, and Children ([WIC] http://www.fns.usda.gov/wic) or Head Start (http: //www.acf.hhs.gov/programs/hsb). Investigate mobile care units for which you can volunteer. The Health Resources and Services Administration (http: //www.hrsa.gov) has comprehensive information on federally qualified community, migrant, and homeless health centers. Partner with Volunteers in Health Care (http://www.volunteersinhealthcare.org), a national resource center funded by the Robert Wood Johnson Foundation for organizations and clinicians caring for the uninsured. Become an advocate with an organization such as the Children’s Dental Health Project (http: //www.cdhp.org), whose mission is to advance policies that improve children’s access to oral healthcare. Also consider being a mentor. In this capacity, you can help educate other healthcare professionals such as physicians, nurses and nurse practitioners, physician assistants, certified nurse midwives, public health nurses, and nursing home administrative and caregiving staff about the importance of preventative oral healthcare and how to identify oral health risk factors, signs and symptoms, and other red-flag indicators.


Remember that money talks.
One of the most important ways to support any cause is to support it financially. For a cause such as access to care, strong funding is a key element to facilitating a true and dramatic shift to ensuring the nation’s positive oral health. Any provision of healthcare is expensive in the United States, and dentistry is no different. By many conservative estimates, access to care issues for dentistry alone costs financial shortages well into the millions of dollars every year. Organizations such as the National Children’s Dental Foundation are seeking regular monthly contributions in order to make an impact on the access to dental care for the nation’s children.

The access to care issues are complex and formidable, and this list is by no means exhaustive. If you or your practice is involved in legislation, education, advocacy, or fundraising for access to dental healthcare, please let us know by writing to the managing editor at: letters@insidedentistry.net. We may publish news on your activities in future issues.

National Problems Demand National Support
“We need to be prepared to serve a broader category base of patients. This calls for more expansive dental acts. Access to care is a national problem that requires national attention,” says Paul Glassman, DDS, MA, associate dean for information and education technology at The University of the Pacific School of Dentistry.

There is little doubt that the publication of Oral Health in America: A Report of the Surgeon General1,2 by the US Department of Health and Human Services in 2000 sent shockwaves throughout the dental profession as well as the dental industry. Since then, the Report—which was authored by then-Surgeon General David Satcher, MD, PhD—has generated much discussion, debate, and dialogue on the problems facing dentistry, so much so that in 2003 the Office of the Surgeon General issued a follow-up report, National Call to Action to Promote Oral Health.1,3 In this report, the current Surgeon General, Vice Admiral Richard H. Carmona, MD, MPH, FACD, continued to sound the alarm to policymakers, community leaders, private industry, health professionals, the media, and the public, challenging each of these stakeholder groups to “affirm that oral health is essential to general health and well-being and to take action.”

That call is now echoing in the halls of Congress. In December 2005, Rep. Charles Boustany (R-LA) introduced H.R. 4624: Special Care Dentistry Act of 2005. Co-sponsored by Rep. Robert Andrews (D-NJ), this bill aims to “amend title XIX of the Social Security Act to require States to provide oral health services to children and aged, blind, or disabled individuals under the Medicaid Program, and for other purposes.” In January the bill was referred to the House Subcommittee on Health. Since a vast majority of the bills introduced in House committees are rejected before they are ever presented to the House as a whole, calling or writing your Congressman or Congresswoman could have significant impact as the subcommittee considers the bill’s merit. For more information on H.R. 4624, visit http://www.govtrack.us/congress/bill.xpd?bill=h109-4624.

References
1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General (2000 & 2002); National Call to Action to Promote Oral Health (2003). Rockville, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research.

2. The full text of Oral Health in America can be found at http://www.surgeongeneral.gov/library/oralhealth.

3. The full text of the National Call to Action can be found at http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.htm.

So, How Are the Kids?
Many statistics about disadvantaged children are disheartening. Even without looking at the numbers we all know these children suffer from lower literacy rates and higher mortality rates. We all know that they are at risk of being victims of inadequate education, inadequate nutrition, and inadequate healthcare.

But disadvantaged children also tend to have many dedicated advocates working to make their lives a little bit better. Organizations such as the Special Olympics and the Make A Wish Foundation are positive examples of passionate people making a difference for millions of kids.

Disadvantaged children have many such people working to ensure that they receive proper and appropriate dental healthcare. One of these advocates, Joseph Greenberg, DMD, founded the Kids Smiles Dental Center (http://www.kidssmiles.org) in Philadelphia, PA. The center’s outreach program has provided basic and comprehensive screening and treatment to more than 20,000 children since it began in January 2001. Dr. Greenberg’s mission and vision is long term. “The future of our nation’s workforce is partly reliant on the dental health of today’s children,” he explains. “Without a self-confident, healthy smile, an individual is not as likely to get a job,” he adds. Kids Smiles is “dedicated to treating the whole child to develop positive dental health.”

The American Dental Association sponsors the “Give Kids A Smile®” program. The program originated when a group of dentists set up a temporary full-service clinic that treated nearly 400 children over 2 days in February 2002. After 4 years of ever-increasing interest and growth, the campaign in its current form is meant to accomplish two things: to help children get the dental care that they desperately need and to raise public awareness that our children deserve a better dental healthcare system that can address their specific dental needs. When the 4th annual Give Kids A Smile National Children’s Dental Access Day was held this past February, more than 512,000 children in over 2,000 locations across the country were screened and treated by 12,000 participating dentists and 27,000 participating dental team members. But the program does not rest on its laurels, as shown in this posting on its Web site (http://www.ada.org/prof/events/featured/gkas/index.asp): “A one-day event like Give Kids A Smile isn’t a cure-all; it’s a wake-up call. People shouldn’t have to depend on charity for basic dental care. It’s time for politicians, parents, and others who care to work together toward a solution.”

It’s not just individual dentists and large professional associations who are working tirelessly to improve the oral health of disadvantaged children. Many dental manufacturers have implemented comprehensive education, treatment, and outreach programs to reach this segment of the population. Two of the largest and longest-running initiatives are sponsored by two of the leading dental manufacturers: Procter & Gamble and Colgate-Palmolive. P&G’s “Crest® Healthy Smiles” (http://www.crest.com/healthy_smiles) is striving to “combat America’s oral health epidemic by improving the oral health of more than 50 million American children and their families by 2010.” Also by 2010, Colgate-Palmolive’s “Bright Smiles, Bright Futures” (http://www.colgate.com/app/Colgate/US/Corp/CommunityPrograms/Bsbf.cvsp) oral health initiative predicts it will have provided education and treatment to 100 million children. And Ultradent has made it its mission to help stop hate crime against cultural and ethnic minority groups by improving the disparities in education and awareness with the “Smiles for Diversity” program (http://www.smiles-for-diversity.org), which was created by Ultradent’s founder, Dan Fischer, DDS.

These are just a few examples of how the dental industry is doing its part to affect change in access to care. Look for more information in future issues of Inside Dentistry on these and other programs addressing the many and multifaceted access to care issues.

Working together, individuals, professional associations, dental manufacturers, state associations, nonprofit organizations, universities, and government agencies can make great strides in improving the access to dental healthcare for our nation’s disadvantaged children. Through collaboration and cooperation, these children’s futures could indeed be healthy and bright, just like their smiles.


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