By now you may be having second thoughts about biting into the saltwater taffy your colleague brought back from the shore. American dentistry is expensive; you are expected to stump up sizable copays even when you have insurance; and if you live outside a major population center, you might not be able to find a dentist, anyway. What on earth can be done to address these problems?
There is no single solution—and in all likelihood, dentistry will see little change as the nation focuses on the more attention-grabbing problems in the larger health care system. People like White House Budget Chief Peter Orszag ignore the problem of spiraling dental care costs because getting them under control won't do much to "bend the cost curve" for health care spending overall. (The current proposed health care reform legislation doesn't say much about oral health.) Dental health represents less than 5 percent of all health care spending. Columbia's Burton Edelstein observes further that Washington policymakers "tend to come from the segment of the population that has not experienced this type of problem. And if you've never had a toothache, you've never had a toothache."
It's clear that low fees and bothersome paperwork aren't the only reasons dentists avoid Medicaid patients. Letting people with bad teeth, often from lower socioeconomic backgrounds, into their waiting rooms risks upsetting dentists' full-fee patients. But under the current market conditions (undersupply of dentists, high demand for services), it seems unlikely that anything short of a massive influx of funds into the Medicaid system will cause a change of heart. The Children's Health Insurance Program reauthorization that President Barack Obama signed into law on Feb. 4, 2009, may offer some relief. The act made it possible for federally qualified health clinics to contract with private dentists to work in their clinics—so if a dentist's private practice is shuttered on Thursdays, she can work one day per week in a clinic. (Of course, this might well require some infrastructure investment. Clinics' dental chairs are already full during opening hours. Funds from the American Recovery and Reinvestment Act—the stimulus bill provided $2 billion for grants to health centers through 2011—may help.)
The American Dental Association denies that there is a shortage of dentists. To the ADA, the situation is entirely a matter of geographic maldistribution. Since rural or inner-city practices are often not financially viable for dentists, "nonmarket forces," which is to say public or philanthropic programs, are necessary if rural residents are to get even basic dental care. An article in the July 2007 issue of the Journal of the American Dental Association suggested
facilitating the travel of [patients who live in counties without any practicing dentists] to dentists in other counties, facilitating and subsidizing the travel of dentists to counties without a private practice dentist, or subsidizing the incomes of dentists so that their total income is competitive with dentists in other areas.
Many states and universities offer residencies and programs to encourage students to consider rural practices. The Washington State Dental Association, for example, has a program called the Rural Internship in Private Practice, under whose auspices a couple of freshman dental students live and work with rural dentists for two weeks during the summer. They work as dental assistants in the practice, go to Rotary Club meetings and Little League games, and generally get a sense of what it's like to live in a small town.
Rather than tackle the problem with such piecemeal solutions, some experts have suggested that a year of postdoctoral residency training, currently compulsory before full licensure is granted in Delaware and New York, be made mandatory nationwide, with the time being spent working in rural areas, community health clinics, or on Indian reservations. Alternatively, loan-repayment schemes can be made contingent on serving in areas of most need for a set period after graduation. Dr. Marty Lieberman, dental director of Seattle's Neighborcare Health clinics, told me that "for so many of the students I talk to, their big fear is the debt they're coming out with." (The ADA reports that the average education debt for the 2007 class of dental school graduates was $169,902.) The National Health Service Corps does offer loan repayment of up to $50,000 for dentists, dental hygienists, and other providers who serve for two years in areas that suffer a shortage of health or dental health professionals. But Bill Prentice, the ADA's senior vice president for government and public affairs, complains that the government has eliminated many of these slots over the course of the last 30 years: "One of the reasons we see these problems in rural and underserved areas is that the government has dropped the ball."
If dental schools expanded class size or if more new schools were opened, the clinics where third- and fourth-year students receive their clinical training could provide more care to low-income patients. Dr. Gene Beck, who attended the University of Louisville School of Dentistry, recommends that schools make a greater commitment to the local communities. "In urban Louisville, we were surrounded by people who needed us but couldn't afford to pay. It would've been so much better if the state had said, 'No matter what, you need to provide care to these people.' That would've given the students mandatory exposure, rather than those few of us who elected to work in homeless clinics or in the Indian Health Service." The Arizona School of Dentistry and Oral Health at A.T. Still University, which enrolled its first class in 2003, follows a "community-based education model," which focuses on "educating competent, compassionate dentists for underserved communities."
Still, growth is likely to be limited. Dental schools are extremely expensive to operate—mostly because of the costs of running clinics—and they have a hard time attracting faculty. Culturally, dentists tend to be entrepreneurial, independent types, and faculty salaries simply can't keep up with income from private practice. According to the American Dental Education Association, a dental school graduate who had completed a one-year residency and three years of specialty training could expect to be hired as an assistant professor in clinical sciences, where the median total compensation (that is salary, fringe benefits, and earnings from a faculty practice) in 2006 was $114,425 at a public university and $92,632 at a private school. By way of comparison, in 2006 the median net income for a specialist in private practice was $296,640. Currently, 379 faculty positions are open around the nation, and the academic work force is graying.
In most professions there are two simple ways to relieve a short-term shortage: import foreign practitioners and improve productivity. Currently, state dental practice acts prohibit dentists qualified outside the United States from practicing here. These protectionist laws ought to be repealed. In the meantime, some dental schools—notably Tufts and NYU—have developed two-year programs to train foreign dentists. The training costs around $100,000—a worthwhile investment over the long term—but they don't attract enough customers to make much of an impact. Since the ADA, which protects the interests of practicing dentists, won't concede that there is a shortage, it is likely to oppose any significant relaxation of the credentialing rules. Technological developments have improved dental office productivity—digital radiographs, for example, are available much faster than the old-school X-rays that took minutes to develop. But there are physical limits to how much dentists can do. As Dr. Chester Douglass pointed out, "This is micro-surgery. Try doing micro-surgery where you are concerned [with] one-tenth of a millimeter—you can't do it for more than 33 or 35 hours per week."
The most immediate and significant change may come out of a current discussion that is perhaps the most contentious in the dental profession: the debate over "mid-level providers." As with the expansion of care by nurse practitioners in the broader health care field, there is a trend toward training dental hygienists and assistants to perform more duties, especially in underserved areas. The best-known program is Alaska's dental health aide therapist initiative, where, after two years of training, a dental therapist is allowed to perform basic dental procedures like fillings and extractions on Alaska natives. In May 2009, Minnesota passed legislation licensing the occupational categories "dental therapist" and "advanced dental therapist" to perform a variety of tasks—only in underserved areas—under the indirect supervision of a dentist. A dental therapist may apply for licensure after graduating from an undergraduate dental therapy program, and after practicing for at least 2,000 hours is eligible to apply to a two-year master's degree program to receive the advanced qualification. This model has been adopted in many other industrialized countries—most famously New Zealand, where the first group of Alaskan midlevel providers trained. Since one of the obstacles to attracting dentists to rural areas is the social and cultural isolation many experience there, it makes sense to train people who feel at home—who are at home—in those areas to provide some of the necessary skills.
Not surprisingly, the ADA is leery of expanding midlevel providers' roles significantly. Responding to a paper assessing the quality of treatment provided by Alaska's DHATs, Dr. Albert Guay wrote in the November 2008 JADA: "It appears that concerns for the availability of oral health care in remote and frontier areas, have overridden concerns for patient safety." The ADA has proposed its own midlevel provider model: a community dental health coordinator who would promote oral health, provide basic preventive services, help the underserved navigate the health care system, and serve as "patient advocates, facilitators, and motivators." But the coordinator would be prevented from actually poking around in patients' mouths.
One obstacle to empowering midlevel providers is that few people will undergo the necessary training until it is clear that there will be jobs for them after graduation. Norma Wells, an associate professor in the department of Dental Public Health Sciences at the University of Washington, told me that in the early 1970s the state of Washington passed a law that allowed dental hygienists and dental assistants to perform some expanded functions such as removing sutures and inserting materials after a dentist had drilled and prepared filling material. The idea was that with four hands rather than two, the office could take care of more dental needs. But very few dentists were willing to pay more to hygienists to do that advanced work.
Bill Prentice of the ADA thinks the midlevel provider debate is a distraction:
If [policymakers] think there's a cheap solution out there, they'll take it. I think this thought that "if we just pass laws creating these mid-level providers, the access to care problem's going to go away" is a myth. Whether it's for a dental health aide therapist or a dentist—there has to be the funding there to assure that people get care. If you give lawmakers and policy-makers the out, they're less likely to do the hard drudgery of actually finding the money to improve the system overall. We've seen how hard it is to get state legislatures to increase funding for Medicaid. That's hard work. It's much easier to just pass a law creating a new provider and have a press conference announcing you've just solved the problem.
Dentists will point out that although dental costs represent a small percentage of health costs overall, a failure to address dental problems can lead to other health problems that can be very expensive to treat. The Deamonte Driver tragedy is a case in point: Because he couldn't get an $80 tooth extraction, the 12-year-old's treatment—which included emergency brain surgery, two weeks in D.C.'s Children's Hospital, and six weeks of physical and occupational therapy—cost the state of Maryland $250,000. And then Deamonte died. In 2008, an analysis of five years of health claims data performed by the University of Michigan School of Dentistry and the Blue Cross Blue Shield Foundation of Michigan found that for people with diabetes, regular periodontal services could lower overall medical and pharmacy costs by more than 10 percent and that diabetes-related medical costs could be lowered by as much as 19 percent. Perhaps health reform's current focus on containing costs and avoiding wasteful health care spending will end the senseless separation of diseases of the mouth from diseases of the rest of the body.
Or maybe not. A nation that is only now beginning to focus on extending health care to the uninsured is almost certainly decades away from taking the necessary steps to ensure healthy teeth for all.
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