Improving Access to Care

I frequently give presentations on access to dental care and dental therapy. When I say that the United States has a significant access-to-dental-care problem, critics usually respond that there is plenty of dental care available to those who seek it or “demand” dental care.¹ Naysayers assert that the problem is poor oral health literacy or individuals making poor choices of how to spend their money. While I agree that poor oral health literacy is a concern, and that some people might make poor spending choices, according to the American Dental Association Health Policy Institute (ADA HPI), the primary impediment to accessing dental care is cost.² My response to this criticism is that we should not be talking about demand for dental care but rather need. There are many serious side effects of poor dental health and it is the professional and moral responsibility of the dental professions and society in general to first help people understand that they need dental care to stay healthy, and then to make dental care more accessible, or affordable.

LACK OF ACCESS AND CONSEQUENCES

In the past few years, approximately 191,000,000 individuals in the US were unable to access dental care on a regular basis.^3–5 Another measure of lack of access is the number of dental health professional shortage areas (DHPSAs). For example, as of December, 2017, the US had 5,866 DHPSAs comprising 62,916,553 people. It is estimated that these areas would require 10,802 dentists to meet those needs.⁶ Finally, nationally, the percentage of children eligible for Medicaid/Children’s Health Insurance Program (CHIP) who received any dental services in fiscal year 2016 was only 48.5%.⁵ These are grim statistics for the richest country in the world.

One outcome of this lack of access is hospital emergency department (HED) visits and hospitalizations for preventable dental conditions. HED visits for dental problems are on the rise across the US.^7,8 Data in Florida illustrate this concern. In 2016, there were 166,997 HED visits and hospitals billed out $322,000,000 in charges. Repeat visits to the HED for nontraumatic dental care are common. In Florida, there were 4,307 admissions as inpatients for nontraumatic dental conditions in 2016 at total charges that exceeded $195,000,000. Thus, Florida hospitals charged more than half a billion dollars for preventable dental conditions.⁸

Another outcome of the lack of access to care is death due to preventable dental conditions. Many people are familiar with the tragic death of Deamonte Driver in Maryland in 2008 when his mother and legal aid attorney could not find a dentist who accepted Medicaid to treat his dental infection. Two more recent studies demonstrate that his death was not an isolated incident. In one study, 66 patients died in hospitals over 9 years from periodontal abscesses.⁹ In the second study, 101 people who went to a HED for a dental problem died there; the vast majority of these patients had no other presenting conditions that posed complicating factors.¹⁰ Both of these studies demonstrate the serious effects of lack of access to oral health care on the US population.

One of the important ways out of poverty for children is education, but if you are in pain while in school or you miss school frequently because of dental problems, you cannot learn. Over the past few years, a number of studies have shown the effects of dental problems/pain in young school-aged children on learning. These included:

• Preventing and treating children’s oral health problems improve functioning, educational achievement, and psychosocial development
• Children with poor oral health and general health are more than twice as likely to perform poorly in school
• Developmental delays among preschool-aged children from families with low incomes may be associated with increased decayed, missing, and filled surfaces on primary teeth
• Among children and adolescents ages 5 to 18, oral pain and acute asthma similarly affect school attendance; absences associated with oral pain or infection increase the likelihood of poor school performance, whereas absences for routine oral health care do not¹¹

Finally, there is a growing scientific literature on the effects of poor oral health, particularly periodontal disease, on systemic health including diabetes, atherosclerotic heart disease, and low birth weight premature births.^12–14 While the gold standard, double-blind, placebo-controlled studies have been less than fruitful, a very recent paper has actually stated a causal relationship.¹⁵

These examples clearly document that poor oral health can have devastating effects on morbidity, mortality, school learning, and systemic health, resulting in more medical illnesses and higher health care costs than in individuals with better oral health.

CONCLUSIONS

This discussion abundantly demonstrates that there is a severe access-to-dental-care problem in this country. In a recent guest editorial, Marko Vujicic, PhD, vice president of the ADA HPI, stated that the dental care system in this country is “stuck.”¹⁶ I also strongly endorse the recommendations of his editorial, which were fourfold:

1. Address the dental coverage gap
2. Define and systematically measure oral health
3. Tie reimbursement, partly, to outcomes
4. Reform the care delivery model (ie, get dentistry out of its care delivery silo)

Vujicic also suggests that dentistry should engage the rest of the health care system to nudge people into dental care and to rise above the scope-of-practice turf wars fueled by fee-for-service payment. I couldn’t agree more!

REFERENCES

1. Guay AH. Access to dental care: Solving the problem for underserved populations. J Am Dent Assoc. 2004;135;1599–1605.
2. Vujicic M, Buchmueller T, Klein R. Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Aff (Millwood). 2016;35:2176–2182.
3. Vujicic M. State of the dental market: outlook 2018. American Dental Association Health Policy Institute. Available at: ada.org/en/science-research/health-policy-institute. Accessed September 18, 2018.
4. American Dental Association Health Policy Institute. Dental Care Utilization, Dental Benefits Coverage, and Cost Barriers: Update 2015. Available at: ada.org/en/science-research/health-policy-institute/publications/all-hpi-publications. Accessed September 18, 2018.
5. Medicaid. Early and Periodic Screening, Diagnostic, and Treatment. Available at: medicaid.gov/medicaid/benefits/epsdt/index.html. Accessed September 18, 2018.
6. Henry J. Kaiser Foundation. Dental Care Health Professional Shortage Areas. Available at: kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed September 18, 2018.
7. Singhal A, Caplan DJ, Jones MP, et al. Eliminating Medicaid adult dental coverage in California led to increased dental emergency visits and associated costs. Health Aff (Millwood). 2015;34:749–856.
8. Wall T, Vujicic M. Emergency department use for dental conditions continues to increase. Available at: ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0415_2.ashx. Accessed September 18, 2018.
9. Shah AC, Leong KK, Lee MK, Allareddy V. Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: a longitudinal trend analysis. J Endod. 2013; 39:1104–1110.
10. Allareddy V, Rampa S, Lee KM, Allareddy V, Nalliah RP. Hospital-based emergency department visits involving dental conditions: Profile and predictors of poor outcomes and resource utilization. J Am Dent Assoc. 2014;145:331–337.
11. Oral Health and School Readiness and Performance. National Maternal and Child Oral Health Resource Center. Available at: mchoralhealth.org/highlights/school-readiness.php. Accessed September 18, 2018.
12. Nasseh K, Vujicic M, Glick M. The relationship between periodontal interventions and healthcare costs and utilization. Evidence from an integrated dental, medical and pharmacy commercial claims database. Health Econ. 2017;26:519–527.
13. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Impact of periodontal therapy on general health. evidence from insurance data for five systemic conditions. Am J Prev Med. 2014;47:166–174.
14. Avalere Health. Evaluation of Cost Savings Associated with Periodontal Disease Treatment Benefit. Available at: pdsfoundation.org/downloads/Avalere_Health_Estimated_Impact_of_Medicare_Periodontal_Coverage.pdf. Accessed September 18, 2 018.
15. Bale BF, Doneen AL, Vigerust DJ. High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgrad Med J. 2017;93:215–220.
16. Vujicic M. Our dental care system is stuck. And here is what to do about it. J Am Dent Assoc. 2018;149:167–169.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2018;5(10):13–15.