The Caries Conundrum
How we continue to fail the patients who need us most
Studies of 2000-year-old mummies show that ancient humans suffered devastating effects from dental caries.1 Yet, in 2015 this almost entirely preventable oral disease is the most common chronic disease of childhood, and untreated caries continues to affect the health of many children and adults in the United States. Shouldn't we have a better way to address this preventable disease by now?
Although there are fewer cavities overall than there were 20 years ago, not every population group and not all regions of the country have shown the same improvement:2At least 20% of Americans have one or more untreated cavities.2
Lower income Americans are twice as likely as other adults to have untreated tooth decay.2
Nearly half of all 5-year-olds have already experienced tooth decay.3
Untreated decay in school-aged children doubles from 14% to 31% when a child is from a low-income household.4
52% of new military recruits couldn't be deployed because of dental problems.5
25% of adults 20 to 44 years old have at least one untreated cavity and 20% of adults older than age 65 have untreated decay.2
The 3-Legged Stool of Oral Health Access
Lowered rates of tooth decay and good oral health depend on what Kathy Hunt, RDH, project director for Kansas Cavity Free Kids, a statewide preschool caries-prevention program for the Kansas Head Start Association, refers to as accessibility to the 3-legged stool of oral health access. Affordability of dental care is the most important leg, she says, but all three legs are needed to keep the stool standing.
• Leg 1: People must be able to afford dental care—to be able to pay for it out of pocket/have dental insurance/have Medicaid to help cover costs.
• Leg 2: People first must be able to find dentists who accept their insurance and then get to the practice location. In many parts of the country, that can be a tall order.
• Leg 3: People must be willing to access dental services—that is, to understand the importance of oral health and act on that. Ms. Hunt calls this leg the most challenging.
All of these factors must be present because they are intertwined. The bottom line is, without regular dental care, patients are not getting preventive care, early diagnosis of decay, or interventions that can halt or slow tooth decay. Every missed visit with dental professionals is a missed opportunity for treatment and patient education about preventing caries.
Affordable Dental Care
While income is by no means the only reason caries persists as a problem, it does strongly influence who visits—and doesn't visit—the dentist, and forgoing regular dental care has a strong impact on levels of tooth decay. According to Beth Truett, chief executive officer of Oral Health America (OHA), a recent Harris Poll for OHA found 70% of those with a household income under $50,000/year cite financial reasons and a lack of dental insurance for skipping or delaying visits to a dentist. In addition, Americans making less than $50,000/year also spend less time on their personal daily oral hygiene.
The percentage of US adults with private dental insurance has been declining for 15 years.6 More than one third of Americans do not have any dental care coverage, and those with some dental benefit often have high cost-sharing.7 While the use of dental services among children is on the rise because of recent Medicaid expansion that makes dental services mandatory for children, use of dental services among adults is in steady decline, with only 35.4% of working-age adults visiting dentists in 2012.8
For adults on Medicaid, finding a dentist has gotten harder than ever. Only about 20% of US dentists treat Medicaid patients.7 Most state Medicaid programs provide emergency dental services but fewer than half of states provide coverage for any other types of dental care; 21 states provide either no dental benefit or emergency coverage only through adult Medicaid.8,9
Approximately 47 million people in the United States live in dental health professional shortage areas, where it is difficult to access dental care.7 There are approximately 190,000 dentists practicing in the United States, a number too low to meet current needs, and they are unevenly distributed across the country.7 Not enough dentists practice in rural and poorer areas of the country, and only a minority see Medicaid patients. For economically disadvantaged people in rural areas, transportation is a big problem if they must take time off from work or school to travel long distances to reach a dentist.
Compounding the issue, the average age of US dentists is over 50 years, so throughout the next decade we will see an increasing number of retirements. Dental schools are not graduating adequate numbers of dentists to replace those who are retiring.7
Frank Catalanotto, DMD, chair of the department of community dentistry and behavioral science at the University of Florida College of Dentistry, believes that this situation calls for a new work force model for dentistry, which the American Dental Association (ADA) does not endorse. "Midlevel providers, or dental therapists, would lower the cost of care per patient and be better able to reach out to patients, because you try to train individuals in the communities the patients come from—rural, underserved, poor communities. This would lower the cost of care," he says. Midlevel providers are similar to physician assistants and advanced practice registered nurses. These providers are already in use in Alaska and Minnesota, and Maine has passed legislation to allow them. North Dakota, Kansas, and Ohio are close to enacting legislation to allow midlevel providers in dentistry.
Understanding the Need to Seek Dental Care
Across all household income levels, an individual's belief that he or she doesn't need dental care is a common reason not to visit dentists.6 Dental care seems optional to some people because most of the public does not understand its importance. The ADA's new ad campaign highlighting oral health care literacy recognizes the need to do a better job of teaching oral health care literacy and is aimed at long-term change in public perceptions.
No one should suffer from chronic dental pain, says Terri Chandler, RDH, founder and executive director of Future Smiles, a school-based dental hygiene program in Nevada. "But many people simply don't have the dental literacy to make that leap to optimal oral health," she says, especially families in poverty, who often don't realize their children have an oral health issue. "I've seen children who live with chronic dental disease and pain since they were very young, and to them this pain is normal," she explains. It's normal for these patients to monitor the texture of their food, avoid eating anything too hot or too cold, and choose only foods that are soft, Chandler says. "I've screened children with deep tooth decay and possible pulp exposures. When asked if they have any pain, they reply, ‘No, I'm fine,' because they've never known an existence without chronic dental pain." It is through education and prevention that dental disease can be avoided, says Chandler.
The Problem of ED Dentistry
Besides the well-known sequela of pain, infection, and tooth loss from untreated tooth decay, caries contributes to lost work and school days and an increased risk for serious medical conditions like diabetes, heart disease, and poor birth outcomes.10 Losing teeth from untreated tooth decay leads to a diet of largely unhealthy soft, processed foods devoid of fiber and most fruits and vegetables. Missing teeth and a poor dental appearance are also a tremendous barrier to getting employment.8
Eventually, pain and suffering from dental decay lands people in the emergency department (ED).7 It is estimated that untreated caries is behind the 830,590 visits Americans made to hospital EDs in 2009 for preventable dental conditions.11 The cost of ED care for dental problems in 2012 was more than $88 million in Florida alone, where 110,000 people used EDs for preventable dental emergencies.11 But in the ED, these patients can only get pain medication and antibiotics if there's an infection, and then they will be referred to a dentist. Unfortunately, most of these patients can't find a dentist or for some other reason they don't go.
Why didn't these patients visit a dentist sooner, before the problem was so advanced? "When you are poor, it's hard to make a decision that you need dental care because you're trying to make the rent, buy food, buy clothes for the children," says Catalanotto. In his mobile dental practice serving nursing home residents in Louisiana, Greg Folse, DDS, sees elderly patients with crisis-level decay and gum disease. "They couldn't afford dental care, and they've had medical crises that shifted the focus from oral care to medical survival," he says.
Most of the 17,500 visits annually to Kansas EDs for dental-related pain are preventable, Kathy Hunt says. "Diamonte Driver's [the 12-year-old Maryland boy who died in 2007 after infection from an untreated abscess spread to his brain] case was heartbreaking because it could have been prevented at so many places along the way," she says. "We have adults that die that way, too. We don't know the numbers because the death certificates don't reflect that the cause of death was dental decay."
Caries in Children
While the biggest improvement in rates of untreated caries is occurring in early childhood, according to the ADA's latest data,12 dental decay remains the most common chronic disease among school-aged children.7 Improvement in caries rates among children is due in part to expanded dental coverage through Medicaid and the Children's Health Insurance Program through the Early and Periodic Screening, Diagnosis, and Treatment program under the Patient Protection and Affordable Care Act, under which more than 5 million more children became covered by 2014.7 Still, fewer than 1 in 3 children enrolled in Medicaid received at least one preventive dental visit.7 This problem is unlikely to improve as long as few practitioners see Medicaid patients, Medicaid reimbursements to dentists remain so low, the paperwork burden remains so high, and Medicaid patients tend to have high "no show" rates that place an economic burden on participating dentists.
In 48 states, physicians can provide early childhood preventive dental services to children enrolled in Medicaid, Catalanotto notes. Nationally about 9% of Medicaid-enrolled children are getting preventive services from physicians, who do a caries risk assessment, apply fluoride varnish to the children's teeth, and provide parental education about risks for early childhood caries and how to prevent them.
Kansas Cavity Free Kids, a project of Kansas Head Start Association, was founded in 2007 by several Kansas health foundations to lower tooth decay rates in young children. "We want to have our kids enter kindergarten cavity free," says Hunt. The project has increased access to dental care at rural and other dental clinics throughout Kansas, worked to improve the dental knowledge of caregivers, and addressed the many barriers to optimal oral health. "We wanted to focus on younger children so good oral health carries through their whole lives," says Hunt. Sadly, even the youngest children have decayed primary teeth. Parents don't know how important healthy baby teeth are to the health of permanent teeth, Hunt explains. Oral health is not usually addressed during pregnancy nor taught in parenting classes. "The best anti-caries tool we have is fluoride in drinking water, but it's undermined by caregivers who may serve bottled water or who offer children soda and juice," she says. In addition to educating caregivers, the program continues tackling the problem of getting pregnant women and children under the age of 3 to a dentist.
School-Based Hygiene Programs
Some 2000 school-based dental hygiene programs have been stepping in to fill gaps in caries prevention, dental care, and oral health literacy among the most economically challenged, at-risk children around the country.7 School-based hygiene programs are state-based and thus operate under different states' rules as far as credentials, scope, and whether they operate independently of dentist supervision.
Future Smiles, a Clark County, Nevada, nonprofit, is a hybrid of a traditional school-based sealant program, says Chandler. Future Smiles has served low-income students and those covered by Medicaid since 2009, using a mobile team that goes out with portable dental equipment to 17 schools, where 38% of the children they serve have untreated tooth decay. Grants, including those from the Elaine P. Wynn and Family Foundation and DentaQuest Foundation, help offset costs for uninsured children. In 2014 alone, Future Smiles provided oral health education to 5088 students, screened more than 2000 students, and placed dental sealants on 5021 teeth. Future Smiles provides prophylaxis, sealants, fluoride, and digital dental x-rays. A robust case management/care navigation system refers children who need restorative dental services to a network of dental providers in the community.
At-risk families living in poverty are not able to regularly buy toothbrushes and supplies, says Chandler, and Future Smiles disseminates thousands of toothbrushes and dental floss though product donations from OHA and generous foundations. "The children often ask us for products to bring home to their parents," she says.
"The school setting is a perfect environment for preventive services and dental education," Chandler explains. "Direct access dental hygiene providers should be recognized as essential community providers and, as such, be contracted with all healthcare programs—all insurance products—including Medicaid."
In South Carolina, as in most of the nation, the top chronic disease problem among children is dental disease. "School nurses said it was the number one issue they dealt with on a daily basis," says Tammi O. Byrd, RDH, founder and chief executive officer/clinical director of Health Promotion Specialists (HPS), a statewide school-based dental prevention program that contracts with school districts to provide oral health instruction, nutritional counseling, anti-tobacco education, prophylaxis, and application of fluoride varnish and dental sealants. Referrals are made for all needs that fall outside the scope of hygienists' practice.
Each year HPS hygienists use portable dental equipment to provide care to 20,000 children at schools. Before Byrd started HPS, one third of children had untreated dental disease, and approximately 20% had outstanding urgent care needs. Within just 5 years of starting the program, the incidence of regular dental needs dropped to 15.5% and urgent care needs fell to 5.9%. HPS also eliminated the disparity between black and white children receiving sealants.
HPS is now in 45 of 80 school districts in the state and is succeeding in greatly increasing the numbers of dentists who work with the program as restorative partners and accept their referrals of children with Medicaid coverage.
Older Adults Are Also at High Risk
Tooth decay among older adults is also a problem because once they retire, only 9.8% of older adults have any dental benefits.8 This helps explain why 23% of older adults have not seen a dentist in 5 years or more.
Truett says the lack of dental coverage under Medicare is a major issue that is going to get worse. "In 2011, 10,000 people started turning 65 each day. By 2031, those people are going to be in the 85+ age group—the fastest-growing age group, percentage-wise, in the country," she says. Assuming dental costs follow the trends of medical expenditures, at 85, dental costs will be double what they are at 65. "With more diseases, aging, and the likelihood of decreased mobility and ability to perform hygiene, you are looking at a situation in which the overall cost of dental care and ability to afford it will be an even worse situation for all but the wealthiest Americans," Truett predicts.
"The rate of dental caries in older adults is decreasing, but significant discrepancies exist in some population groups," says Linda C. Niessen, DMD, MPH, MPP, dean and professor of the College of Dental Medicine at Nova Southeastern University in Florida. There are income and education disparities, and African American and Hispanic seniors and those with lower income and less education have more untreated decay.4
"Dentists need to be aware that untreated tooth decay is not just a problem in children; it's also a problem in older adults. And you're going to have many older adults in your practice because there are more people over 65 now than there have ever been, and if they still have teeth they are at risk for tooth decay," says Niessen. Baby Boomers have more teeth than previous generations of older people, which in many cases means more decay. "Prevention is not just for kids anymore," she advises. There should be a preventive care plan for patients that keeps in mind that older patients may have physical impairments impeding their ability to brush or floss properly. Niessen recommends flossing-assisting devices such as interproximal cleaners to help clean in between the teeth, helping prevent more decay.
Older adults are also at higher risk for caries because they are taking multiple medications that dry out their mouth. "Xerostomia contributes to inception and progression of dental caries," says Niessen. Dentists must first take a complete medical history and know what medications patients are taking; if any cause dry mouth, make sure patients are aware of it and that their hygienist educates them about the issue. Hundreds of medications reduce salivary flow, including antihypertensives, antidepressants, and decongestants. People with conditions causing lower salivary flow or viscosity have a rapid increase in caries rate—this includes patients with diabetes. "We don't talk enough about saliva," agrees Joel Berg, DDS, MS, of the Center for Pediatric Dentistry, and dean of the University of Washington School of Dentistry. "Every dentist should chart every child and every adult patient's saliva for flow rate and viscosity."
Older adults in nursing homes, especially those with dementia, depend on caregivers to do daily oral care. Unfortunately, dental operatories are rarely found in nursing homes, so many residents have few opportunities for dental care, especially because transport to and from dentists' offices can be expensive and difficult. Folse has a mobile dental practice that visits 22 different nursing homes in Louisiana. "I see a huge burden of disease, including crisis levels of decay and gum disease when the residents arrive," says Folse. "I've seen deaths directly related to dental disease in nursing home patients multiple times in my practice."
In 1992, 80% of his nursing home patients had no teeth; now 75% to 80% get to the nursing home with teeth, and some 80% to 90% of those with teeth have decay. "They don't just have one cavity, they have cavities on most of their teeth. If there are cavities on 15 of 20 teeth, what do you recommend to a sick nursing home patient? Do you restore them all, take some teeth out, or maintain with prevention only? Dentists have multiple ethical options that require deep thought, professionalism, and consultation with responsible parties to determine the best treatment," Folse says.
With no dental coverage through Medicare and the state's Medicaid paying only for dentures and partials, most nursing home patients purchase dental services or insurance using their social security income. The ADA provides useful information and reimbursement tools for long-term care residents by detailing the laws regulating Incurred Medical Expenses. Dentists interested in caring for nursing home residents can find out more from the ADA's self-paced online continuing education course on dentistry in long-term care (see the Resources box for more information).
What's on the Horizon?
Good caries management depends on assessing risk levels to determine the likelihood of new cavitated or incipient caries lesions during a certain time period, or the likelihood of a change in the size or activity of current lesions (Table 1). "Caries is a $75- to $80-billion-a-year disease, which makes it one of the most expensive diseases in the country," Berg states. Most of that is spent on treating the results of caries, not the disease itself. There is a race to come up with a therapeutic agent that would be available once there is a detection tool that justifies third-party payers compensating a dentist to use it, he says.
Activity in caries research will be in the science behind the oral biofilm, because the hope is to create a drug that attacks the oral biofilm. "We need to study the biofilm and understand the relationship between the microbiome and the host, and to prevent caries by signal interruption between the different organisms in the biofilm," says Berg.
Sometime in the next decade, perhaps, there could be a rinse that disrupts the biofilm's ability to metabolize sugar so that the risk of caries would be significantly reduced. Certainly that would be a welcome innovation, for as Tammi Byrd wisely reminds us: "No disease has ever been eliminated or cured by treating it; it's always by prevention."
Caries Assessment and Management
The CAMBRA (CAries Management By Risk Assessment) protocol weighs a combination of factors, including diet, fluoride exposure, and susceptible host and microflora that interact with behavioral and social factors contributing to caries development.
The individualized risk picture that CAMBRA provides helps tailor treatment planning and prevention strategies. The ADA and AAPD provide CAMBRA templates to guide clinicians through diagnosis, interventions (fluoride, diet changes, and sealants), and restorative management.
CAMBRA tools focus attention on risk and managing risk, and are thus a good thing for the patient, says Joel Berg, DDS, MS. Another advantage is that it is inexpensive to implement, with cost coming from time rather than capital investment.
Newer ways to help determine caries risk include chairside tests of saliva, plaque, and biofilm activity or ATP bioluminescence. New technologies that add to visual inspection and radiographs to help identify individual lesions on teeth include transillumination, laser fluorescence, and imaging devices. Although these technologies are highly sensitive, Berg cautions that most of the marketed devices are either overly sensitive (too many false positives) and/or not specific (too many false negatives), so there is a high risk of overassessment and overtreatment.
Without clinical trials showing their usefulness, insurers won't compensate for assessment procedures with these technologies out of concern for overtreatment. Perhaps overtreatment is not as great a concern if it leads to the use of fluoride, calcium phosphate, or xylitol, though it adds cost to the system. "But light-based systems primarily have been used to detect caries lesions that results in restoring them, so it's not changing that paradigm," says Berg. We don't yet have the technology that is reliably specific enough to identify early caries lesions that could then be treated with medicinal therapies to prevent cavities needing restorative dentistry.
1. Brice M. Ancient Egyptian mummy reveals man who died from mouthful of cavities. Medical Daily. www.medicaldaily.com/ancient-egyptian-mummy-reveals-man-who-died-mouthful-cavities-243024. October 10, 2012. Accessed January 28, 2015.
2. Selected oral health indicators in the United States, 2005-2008. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/data/databriefs/db96.pdf. May 2012. Accessed January 28, 2015.
3. The state of dental health: pregnancy and early childhood. Children's Dental Health Project. www.cdhp.org/state-of-dental-health/pregnancy-early-childhood. 2014. Accessed January 28, 2015.
4. Oral health in the U.S.: key facts. Kaiser Family Foundation. kff.org/disparities-policy/fact-sheet/oral-health-in-the-u-s-key/. June 1, 2012. Accessed January 28, 2015.
5. The state of dental health: School years and beyond. Children's Dental Health Project. www.cdhp.org/state-of-dental-health/schoolandbeyond. 2015. Accessed January 28, 2015.
6. Yarbrough C, Nasseh K, Vujicic M. Why adults forgo dental care: evidence from a new national survey. American Dental Association website. www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1114_1.ashx. November 2014. Accessed January 28, 2015.
7. Sanders B. Dental crisis in America: the need to expand access. Bernie Sanders United States Senator for Vermont website. www.sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT.pdf. February 29, 2012. Accessed January 28, 2015.
8. A state of decay: Are older Americans coming of age without oral healthcare? Oral Health America. b.3cdn.net/teeth/1a112ba122b6192a9d_1dm6bks67.pdf. 2014. Accessed January 28, 2015.
9. Dental Care for Medicaid and CHIP Enrollees. Medicaid.gov. www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Dental-Care.html. Accessed January 28, 2015.
10. Advancing oral health in America. National Academy of Sciences. www.iom.edu/Reports/2011/Advancing-Oral-Health-in-America/Report-Brief.aspx. April 8, 2011. Accessed January 28, 2015.
11. A costly dental destination. Hospital care means states pay dearly. The Pew Charitable Trusts. www.pewtrusts.org/~/media/Assets/2012/01/16/A-Costly-Dental-Destination.pdf. February 2012. Accessed January 28, 2015.
12. Palmer C. American dental association statement: CDC data shows early childhood caries trending down. American Dental Association website. www.ada.org/en/press-room/news-releases/2014-archive/october/cdc-data-shows-early-childhood-caries-trending-down. October 28, 2014. Accessed January 28, 2015.
13. Guideline on caries-risk assessment and management for infants, children, and adolescents. American Academy of Pediatric Dentistry. www.aapd.org/policies. 2015. Accessed January 28, 2015.
14. Kutsch VK. Caries detection. Inside Dental Assisting. 2012;8(2). www.dentalaegis.com/ida/2012/04/caries-detection. Accessed January 28, 2015.
Dentistry in Long-Term Care
Health Promotion Specialists
Kansas Cavity Free Kids
Oral Health America