The Dental Divide

I once worked for a community dental clinic in northern California that served low-income, mostly uninsured families.  I was shocked by what I saw:  four year old children forced to endure the constant, nagging pain of dental abscesses; adults who had lost all their teeth by the time they were 40; and an alarming lack of knowledge about how to maintain healthy teeth.  I don’t think I’ll ever forget the homeless woman who desperately attempted to fashion her own dentures out of play dough and stale bread.

All too often, people think of dental care as a medical luxury.  And yet it is an essential component of overall health.  Dental disease is linked to heart disease, stroke, diabetes, and more.  Maternal periodontal disease has been linked to pre-term births.  According to the National Children’s Oral Health Foundation, pediatric dental disease is 5 times more common than asthma and 7 times more common than hay fever.  Among low-income adults, unchecked dental disease is a fundamental barrier to getting out of poverty because rotten and missing teeth prevent individuals from obtaining a job.

A recent article in The Atlantic showed (not surprisingly) that the rate of dental visits across the U.S. closely tracks socioeconomic status.  People who possess college degrees and work in professional fields see the dentist more often.  People who live in states with the lowest uninsured rates see the dentist more often.  People who live in Massachusetts and Connecticut are more likely to have seen a dentist in the past year than those who live in the South.

Keri Discepelo, D.D.S. and Andrew Kaplan D.M.D. (class of 2012) cite new opportunities to increase access to dental care and reduce disparities in their article, The Patient Protection and Affordable Care Act:  Effects on Dental Care.  Keri and Andrew note the access issues faced by some 40% of Americans who don’t have dental insurance, a dental safety net that’s stretched thin, and the fact that the majority of private and group practice dentists are not Medicaid providers (since the reimbursements are low and don’t cover costs).  With the current economic crisis, more states are eliminating the dental benefit from their Medicaid programs entirely, at least for adults (see: California).

Keri and Andrew helpfully summarize PPACA’s major oral health provisions which particularly benefit children and also increase prevention education across the country.  They also outline different strategies to improve dental health access and outcomes.  These include using  dental “auxiliary” staff like hygienists, dental assistants and community health workers to provide prevention education.  More controversial is the development of mid-level practitioners to provide a basic level of dental care which could particularly help rural or underserved areas facing dentist shortages.  Interestingly, their article also outlines the differences of opinion about PPACA among different facets of the dental profession (there was resounding opposition to the mid-level provider idea and the ADA opposed the bill because it didn’t address Medicaid reimbursement issues and because it didn’t define a basic adult dental benefit for coverage).

One young mother came to our clinic after she’d lost her front teeth in a car accident.  She didn’t have insurance, but thanks to donations we were able to provide her with new front teeth.  We took two photographs of her – before her new dentures, and after – and mounted them side by side.  On the left you saw the hopeless gaping smile of a disadvantaged person.  On the right you saw a gorgeous, confident, professional-looking brunette with big brown eyes and a warm smile.  Two different people facing two different futures.

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