A joint investigation with

How To Fix A Broken Dental Safety Net

by
Watch Dollars and Dentists, FRONTLINE’s investigation into the the flaws in our dental system.

A trip to the dentist’s office may instill a sense of dread, but for the majority Americans, access to care is rarely an issue.

For roughly one-third of the population, though, finding a dentist can seem next to impossible. The problem is especially acute for the poor and for those in rural areas. Currently, more than 49 million people live in areas where it is difficult to access care, according to the Department of Health and Human Services, while a separate analysis [PDF] by the Pew Center for the States found that upwards of 17 million low-income children go each year without seeing a dentist.

“The dental system that we have works pretty well for most people, particularly those who have money and transportation and don’t need very much,” according to Shelly Gehshan, director of the Pew Children’s Dental Campaign.

“But if you are anyone else — if you are in an institution, a nursing home, a prison, if you have special needs of any sort, if you are a young child, if you’re a low-income person, rural, if you’re in that one-third of the population, it’s not so much that the system is broken, I would say there isn’t one for them.”

FRONTLINE spoke with Gehshan about the scope of the problem, its implications, and ways to remove barriers to access. This is an edited transcript of that conversation:

Most people are shocked when they learn how many Americans lack access to proper dental care. Why does this issue fly so far under the radar?

It’s a great question. Basically, about two-thirds of Americans have good access to care and the other third have enough challenges that this is not at the top of their list. So most of the people in power in this country, in legislatures or in policy-making positions, or even in the press or associations, they’re in the two-thirds that either have insurance, or they have money to pay for care, or they grew up in homes where there was knowledge about dental hygiene and access to a neighborhood dentist.

Those that are in the one-third that lacks access know very clearly that there’s a problem. They may be people who work but don’t have a lot of time or extra disposable income to go pay for care. They delay care when they don’t have enough money, and if there’s a problem they’re just stuck with it and they may not be able to figure out what to do.

When you consider all the challenges facing oral health in the U.S., what worries you most?

I think the dentists and dental associations don’t necessarily see that there’s a problem. They’re practicing their profession as they were taught, in good faith. They do a good job; they do the best job they can with their patients, and they don’t necessarily understand that there’s an access problem. And therefore their associations often are not pushing for changes that might help the substantial numbers of people who are left outside the system.

How does poor oral health affect a person’s overall health?

There are many links between oral health and general health that are concerning. When you think about it, the mouth is the portal to the body. … There are many links with serious implications between poor dental health and diabetes, and cardiovascular disease. There are many suspicions about links to preterm birth and infant mortality. An infection in the mouth is just as serious as an infection anywhere else in the body, so people who are walking around with a toothache are generally harboring some sort of infection or problem that is going to impact their overall health.

What I generally worry about, though is the impact on life. If you’re a child with poor dental health, you may not be able to eat, or play, or learn, or sleep normally. There are kids that don’t smile because they’re embarrassed of what their teeth look like. How does that affect the kids’ social development? And if you’re an adult with poor oral health, it’s really hard to get and keep a job. If you have missing or decayed front teeth, who is going to hire you?

So there are serious implications. It’s not just a cosmetic issue, which is what you would think if you just look at commercials on TV. It’s not just about smiling. It’s about whether you can live your life and thrive.

What are the costs to the medical system of having so many go without proper dental care?

Overall, the problem of people who have no access to care and show up in emergency rooms is rising — it rose 16 percent and probably maybe as many as 1 million people in this country … showed up in emergency rooms for dental problems that were easily preventable. And that is an enormous waste of money because all they can get is pain medication and maybe antibiotics if they can afford to fill those prescriptions. And the ER docs will say call a dentist, but if they had a dentist they wouldn’t have shown up there to begin with. They can’t fix the problem so it’s a complete waste of money. …

The other issue with dental care is that it’s probably 50, 60 years behind medical care in every possible way, but particularly with respect to any measures of quality. There are no diagnosis codes in dental care. For instance, in medical care there’s a lot of research and a lot of measures to show whether providers, or clinics, or hospitals are doing a good job. There are no such things in dental care.

I served on an Institute of Medicine panel that issued its report last July on access to dental care for vulnerable and underserved populations. One reporter had some problems, and he went to, I don’t know, 10 dentists, and he got statements on what was wrong and what the treatment plan was that ranged from $400 dollars worth to $16,000. That can only happen when there are no diagnosis codes and no quality measures and no consistency. You can’t say that one person’s mouth would elicit that variety of responses.

Whereas in medical care, for instance, one quick example is that all the research shows that someone who’s had a heart attack and shows up in the emergency room ought to get beta blockers. There is a diagnosis, here’s a clear treatment that should happen all the time. There are no such things in dental care, so there’s kind of no one, no oversight by federal agencies or by payers like insurance companies.

What’s behind this surge in ER visits? Do we simply not have enough dentists to meet the demand for care?

There’s a huge shortage of dentists in this country. There’s a shortage, and there’s a maldistribution. I think we have the lowest ratio of dentists-to-population than we’ve had in 100 years, and it’s going to get worse before it gets better.

It probably does not help that for many Americans, the only way to access coverage is through Medicaid, but most dentists don’t offer care to those patients. Why are so many slipping through the safety net?

It’s a great question. The safety net only serves roughly 7 million of 8 million of the roughly 80 million or 90 million who are underserved for dental care, so we’re just scratching the surface.

When you think about it, the medical system is much more diverse. If you break your arm, you can go to the emergency room, you can show up at the orthopedist’s office, you can go to your internal medicine doctor and get an X-ray first to see what’s wrong, you can go to an acute care clinic, you’ve got many, many choices. …

If you need dental care, if you’re lucky, you live in one of the communities that has a community health center that has dental, but there are only 1,100 community health centers, and about 600 or 700 of them have dental. So if you don’t live in one of those communities, you’re out of luck. If you can’t afford a dentist or there isn’t one that has capacity to accept you, you’re really out of luck.

“We have the lowest ratio of dentists to population than we’ve had in 100 years, and it’s going to get worse before it gets better.”

Part of it are the laws in place: States have dental practice acts that have provisions in them that basically have restricted where dental care can be offered, and I think that’s a huge part of the problem. They’re called corporate practice provisions, and they govern who can own and operate a dental practice, and what has happened is that those have restricted innovation.

So if you were my brother and you were a pediatrician and I’m a pediatric dentist and we want to open a joint clinic and own it together, in most states we’re not allowed to do that. It would be against the law.

Let’s say I’m a general dentist and I offer the community hospital where all these preventable dental patients are showing up — I want to open a practice there and book myself at 80 percent, so that when those patients come in there’s somewhere for them to go. That’s illegal in most states. It’s meant to protect dentistry as a cottage industry and keep out innovation. Keep out managed care. Keep out anyone else. And it’s meant that we don’t have enough care in enough places to serve enough people.

Is there an equivalent in dentistry to the Hippocratic Oath? How can it be ethical for so many to go untreated?

They don’t have anything similar. I think everybody knows dentists have big hearts and a lot of them provide charity care, but charity is not a system of care. If you’re a poor patient, if you’re a mom of a Medicaid kid, it doesn’t help you that your neighborhood dentist volunteers once a year or twice a year at a charity clinic or at a Missions of Mercy. It doesn’t help you.

What can lawmakers do? Is this a problem that needs fixing at the state level? At the federal level? Both?

It’s both. There are a number of things that have to happen.

What I think has to happen at the federal level is that there needs to be attention to both prevention and funding for care. A public health approach is important. … So one quick example is that the Centers For Disease Control gives grants to states to build their dental public health infrastructure. They’re called infrastructure grants. All states need them. The Institute of Medicine recommended it. The Affordable Care Act recommended it, but there’s only enough money in the CDC budget to fund 20 states for this.

This is the money that gives states the capacity to do surveillance so they figure out where their problems are. I mean, you can’t improve what you don’t measure. It also means that they can plan prevention programs like sealants, because sealants prevent 40 percent of the decay, but the kids that most need them are least likely to get them. And then they plan water fluoridation efforts. We have about a dozen states in this country where the fluoridation rates are really low, and you need that sort of bedrock prevention everywhere because it prevents so much decay and saves so much money …

“Dentists have big hearts and a lot of them provide charity care, but charity is not a system of care.”

The other thing is we need to make payment sources much more universal. It shouldn’t be an optional benefit for adults in Medicaid, and right now states can choose whether they add dental care for adults or not. It should not be optional. And that helps children, too. There’s evidence that shows family seek care together, and so if you cover the parents the children are more likely to get care …

It shouldn’t be left out of Medicare either. I mean, there’s a huge bomb of baby boomers that are edging into Medicare, and a lot of them are going to have a nasty surprise when they get there and realize they have no dental benefits.

The other thing, I would be really remiss if I did not say that there are many workforce solutions that are largely up to states to implement. Almost all developed countries but the U.S. have mid-levels in dentistry. They’re effective. They’re safe … there are many different models that states could adopt. We need more dental extenders who can work for a dentist or under the supervision of a dentist and provide quality care for people who don’t get it. It’s that simple.

That said, it feels as though there is lot of resistance from the dentists themselves to these alternative providers. Why?

I think many dentists have gotten wrong information about this and I think many of them are worried about sort of cut-rate competition, but its not going to be like that.

We’ve done research that shows that dentists, their bottom lines would benefit from hiring new providers just as it benefits now from hiring hygienists, and they could make a go of treating Medicaid patients without losing their shirt. Even with low rates, new providers would allow them to open their doors to Medicaid and CHIP patients. So it’s critical for access, but it’s also critical for the development of the profession. If we had new providers that take on some of the easy stuff, then dentists could start being health care providers, not just providers of procedures. … There’s growth in this for dentists too and I’m not sure they realize that.

What about a model that’s emerged with the help of private equity dollars — so-called “corporate dentistry.” These firms have expanded coverage to millions, but critics fret over their for-profit structure. On the whole, are such providers benefiting the system?

Well given that we have no quality measures, it’s kind of hard to dang anybody on whether or not they’re providing quality care. My basic suspicion is that they are doing the best job they can for their patients, but I think there is a need for research in this area to figure out how to make sure we’re providing quality care to people that don’t have it cause basically what we have on our hands is a big system problem.

You can’t really think of it in one small area, like if I fix financing everything will be better. Well it won’t. If the Affordable Care Act is upheld in part or in whole we’re going to have many, many more children entering the system with dental insurance that they didn’t have before. We do not have the capacity for those children. If you just add new workforce models — like hygienists with extra training, or dental therapists, or expanded function dental assistance — without more financing, that may not fix your problem which is why I think you really have to attack it systemically. You have to think of prevention, you have to think of funding, you have to think of workforce, you have to think of trying to change the system to get more care in more places where people are who need it.

The laws in this country that govern the provision of dental care, many … were written when the most sophisticated technology we had was a big black rotary phone with a party line. We now have technology where all you have to do — there’s a guy who sat next to me in a meeting and showed me an x-ray that somebody had sent him on his iPhone. And he moves the screen, calls back and makes his judgment.

We can link providers to the people they supervise now without having them together physically, and that is a way that we’re going to be able to get care to people in rural areas, or people in institutions, or in schools while still preserving the safety and quality of the care to the satisfaction of the supervising dentist. So it’s a system problem.

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