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12-year-old Maryland boy, Deamonte
Driver, died of an infection triggered by an
untreated dental abscess. A lack of dentists
willing to accept Medicaid patients, along
with glitches in Medicaid paperwork, meant
he did not receive care until the infection
had spread to his brain. His death, reported
in The Washington Post, put a human face on
the problem for Congress.
Concurrently, the issue of mid-level providers—dental
therapists who can do procedures
such as cleanings, restorations or
uncomplicated extractions under the supervision
of a D.M.D. or D.D.S.—surfaced.
Such a model has existed since 2005 on
tribal lands in Alaska, despite an unsuccessful
legal challenge by the American Dental
Association and the Alaska Dental Society.
“Part of the argument in that suit,” Evans
said, “was that no care is better than some
care. And so here I ask: is that our message?”
One positive recent step, he said, was
the formation in 2009 of the U.S. National
Oral Health Alliance, a collaboration of
dentists, educators, insurers, the dental
products industry, physicians and policymakers.
The group focuses on prevention
and public-health infrastructure,
oral health literacy, collaboration between
dentists and physicians in providing care,
financing models and strengthening the
oral health delivery system.
In response to an audience question,
Evans acknowledged that for recent graduates
entering dental practice, the need to
repay student loans plays a key role in career
decisions. “The increasing indebtedness of
students is a huge problem, and it certainly
limits options,” he said. “What I share with
students is that we’re not necessarily expecting
any student to singled-handedly take
on this problem, or even go into a public
health position. Even if they are in private
practice, that is public service, in the sense
that they should be available to all of the
public. Everyone has an opportunity to
find something they can do to ameliorate
the problem, and they should look for those
opportunities.”
the issue that won't go away
among the statistics brandished by dental educator Caswell evans during his talk
at Tufts School of dental Medicine was this: approximately 80 percent of all dental
disease in the U.S. occurs in 20 percent of the population. as a young dentist working
in remote communities and on Indian reservations in the 1980s, Mark nehring
witnessed the human stories behind those numbers.
“I saw more disease than you could ever imagine,” he says of his time working
with the U.S. Public Health Service’s national Health Service Corps and Indian
Health Service in Illinois, Montana and north dakota. In remote regions of these
states, generally beset by poverty, he saw patients whose oral health had often been
neglected for years, “I did procedures and treatments for chronic conditions that
I would never have seen in a suburban practice,” he says. “and I began to question
the existing attempts to contain oral disease. I developed more and more interest
in approaches to preventing the disease that I was seeing in such large amounts.”
So he made the jump from rural clinician to public health administrator, serving
with the federal government during the 1990s and 2000s, when the dental profession
slowly became aware of what is now called oral health-care disparities. In his new
role at Tufts, as the delta dental of Massachusetts Professor in Public Health and
Community Service and chair of public health and community service, nehring wants
to marshal the ideas of students and faculty to address access to care, now the most
daunting challenge in dentistry.
“all of us in the profession—academia, the private sector, the public sector, policymakers—we’re
all part of the solution,” he says.
From 1988 until his arrival at Tufts in February, nehring worked for the Public
Health Service and the Health Resources and Services administration (HRSa) in
Rockville, Md., most recently as the acting chief dental officer for HRSa and chief
dental officer for HRSa’s Maternal and Child Health Bureau. during that time, he says,
public health dentistry was forced to shift its emphasis and approach.
“In the past 30 to 40 years, public health dentists were trying to focus on prevention,”
he says. However, the existing structure within dentistry compensated private
practitioners primarily for treatment. “My take was that public health dentists were
kind of challenging the rest of the profession to do it their way by applying guilt, appealing
to social responsibility. But those kinds of pleas from the public health side
didn’t necessarily fit the private-practice models,” he said.
now public health specialists have begun to focus on ways that access to care
can be expanded and integrated into the private-practice model, nehring says. “The
private practice is the 900-pound gorilla, and you cannot make a difference without
that participation,” he says.
Change will come, nehring says, only if the profession can take full advantage of
the existing workforce. That includes looking at “adequate or fair reimbursement”
by public insurance programs such as Medicaid for private practitioners, he notes.
Other approaches include educating physicians—especially those who treat pregnant
women and children—about the relationship between oral health and overall health;
expanding oral health services to schools and community health clinics and continuing
to assess the role of nontraditional providers, such as dental therapists and hygienists,
in treating underserved patients. “There’s no silver bullet to solve the access
issues,” he says. —helene ragovin
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