A BROADER VIEWOF HEALTH: - UCLA School of Public Health

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4 POOR ORAL HEALTH HAS BEEN CALLED A “SILENT EPIDEMIC,” WITH DISPARITIES AND ACCESS PROBLEMS CALLING FOR MORE ATTENTION FROM PUBLIC HEALTH. WISDOM ON TEETH: A Growing Focus on Dental Care Needs Few public health issues have received more attention in recent years than lack of access to essential medical services UCLAPUBLIC HEALTH “Oral health issues fit so closely with public health’s mission, and through efforts aimed at prevention, education and addressing access issues, we have the potential to get more in return from our investment than from many other investments.” —Dr. Ronald Andersen and its disproportionate effect on certain population groups. Meanwhile, a parallel issue has gone relatively unnoticed. “Access problems appear to be considerably greater with respect to oral health services than general health services, and the disparities by income and minority status are probably larger,” says Dr. Ronald Andersen, professor of health services at the UCLA School of Public Health. “But because dental care isn’t associated with saving lives, it hasn’t been emphasized in public health to the extent that it should be.” Overall, oral health has improved dramatically in the United States over the last half-century, thanks in part to public health efforts such as fluoridation of drinking water and education about the benefits of fluoride toothpaste. It wasn’t long ago that the majority of Americans lost their teeth by middle age; today, most can expect to retain their natural teeth over their lifetimes. But there is significant cause for concern. A decade ago, in the first-ever Surgeon General’s report on oral health, Dr. David Satcher pointed to a “silent epidemic” of dental and oral diseases with “profound disparities that affect those without the knowledge or resources to achieve good oral care.” In addition, although dental care might not seem as critical as medical care, poor oral health can cause significant problems…and can be related to health ailments outside
the mouth. Untreated, tooth decay (cavities) – the most common chronic disease in children – can cause everything from pain and difficulty eating to lost school and work time. Serious oral disorders can undermine self-esteem, inhibiting children and adults from smiling. Gum disease has recently been linked in studies to increased risk for diabetes, heart disease and stroke. And while much attention has been paid to the problem of lack of health insurance, the fact that even more are without dental coverage is often overlooked. Although public insurance programs such as Medicaid have increased coverage for children, dental benefits tend to be vulnerable to cuts in tough economic times. By the same token, for many low-income families struggling financially and, in some cases, lacking education about the importance of regular dental visits, dental care may be viewed as optional. “Oral health issues fit so closely with public health’s mission,” observes Andersen, “and through efforts aimed at prevention, education and addressing access issues, we have the potential to get more in return from our investment than from many other investments.” Dental public health issues haven’t been ignored at UCLA, where faculty in the School of Public Health and School of Dentistry have worked – often together – to address some of the major concerns. One of the key efforts began in 2001 when The Robert Wood Johnson Foundation provided funding for a national demonstration program aiming to reduce dental-care access disparities. Fifteen dental schools were selected to participate in the Dental Pipeline Program, which would receive additional funding from The California Endowment. The program’s national evaluation team was based in the UCLA School of Public Health, with Andersen as the principal investigator and Dr. Pamela Davidson, associate professor of health services at the school, as co-principal investigator. (The original project ended in 2007, but a follow-up study to measure its sustainability is ongoing.) The pipeline program was established in an effort to increase access to dental care in low-income and minority communities by recruiting more students from underrepresented minority groups to dental schools, improving dental school curricula to better prepare students to provide culturally competent care, and providing more clinical practice experiences for students in underserved communities. “If you look at the ethnicity of dentists compared to the distribution of the population, there are greater differences than in medicine,” Andersen notes. That has contributed in part to the shortage of oral health providers in minority communities, he says. Dental schools have faced significant challenges in their efforts to recruit minority students into dental careers, Andersen notes. For one, the shortage of providers in minority communities means there are few family members or friends serving as role models and mentors. Nonetheless, through steppedup efforts, including the establishment of pre-dental programs to assist students in meeting prerequisites, the pipeline program schools increased applications from underrepresented minority students by 77 percent from 2003 to 2007, while enrollment of underrepresented minority students increased by 27 percent. Beyond the effort to increase the number of minority dental providers, the pipeline program sought to revamp education and training experiences that would make all students more likely to consider careers in public health and service to underserved communities. While curricula were revised and the number of days senior dental students practiced in underserved communities increased, it’s unclear whether there was a corresponding increase in graduates going on to practice in these communities. Unfortunately, Andersen notes, dental students tend to enter practice with huge debts; thus, many who want to go into public service positions are deterred by the lower salaries and instead feel compelled to opt for private practice. The problem of disparities in utilization of dental services – particularly among children – is underscored by a recent study conducted by Dr. Nadereh Pourat, professor of health services and director of research for the Center for Health Policy Research, which is based in the school. Using data from the 2005 California Health Interview Survey, Pourat found that nearly 25 percent of California children ages 11 and under had never seen a dentist, and that among those who had, there were significant differences by race, ethnicity and type of insurance in the amount of time between dental care visits (see page 24). Having any kind of insurance significantly increased the odds that a child would see a dentist on a regular basis, but the type of coverage mattered: 54 percent of privately insured children had seen a dentist within the previous six months, vs. 27 percent of publicly insured children (Medicaid or the Children’s Health Insurance Program) and 12 “Public programs are designed to improve access to care for underserved populations, and our study shows that they are successful in doing so. However, they don’t close the gap.” —Dr. Nadereh Pourat 5 feature UCLAPUBLIC HEALTH
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A BROADER VIEWOF HEALTH: - UCLA School of Public Health

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