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Fixing Cavities in America's Dental System

by Francis P. Koster, Ed.D.

If someone invited you to compete for a  prize of  $1000  to quickly create a method to identify poor people by looking at them, you could win easily by saying "Look at their teeth."    One recent study found that by the time the poorest 20% of the population reach aged 70, they have 8 fewer teeth than the top 20%[1]  Many of the remaining teeth are broken in some way. 

Dental problems later in life are usually rooted in childhood.  About 19 million American children (12 million poor) lack dental coverage, and/or do not live near dentists that will see them.[2]   This problem is about to get worse.  About a third of all American dentists are nearing retirement age.[3],[4The existing educational pipeline does not contain enough new dentists to replace all of those retiring and expand to provide services to those currently unable to get a dental treatment.[5]

It is difficult for America's poor to get adequate dental care for two major reasons.  In rural areas there is often a scarcity of dentists,  and in both rural and urban areas where there would seem to be enough dentists, the government run "safety net" Medicaid program reimburses so little that it does not cover the cost of salaries of the dentist and their staff.   In order for dentists to stay in business, they have to limit the number of appointment slots  they can donate to poor patients.   Nationally, 80% of all dentists do not accept Medicaid[6], and the rest understandably only allow a few slots a week. 

Bad dental health impacts employment, because those with poor teeth tend to keep their lips closed, and not smile - making them appear unfriendly and unsuitable for many jobs requiring contact with customers .  This perpetuates the cycle of poverty.

The result is that we can tell with some certainty a person is poor by looking at their teeth.

The dental community has been aware of this painful reality for many years, and everyone from receptionists to dental hygienists to dentists routinely volunteer at church sponsored "dental care for the poor" days held every few months.  But heaven help you if you are poor, have a significant tooth ache, and the next free dental clinic is months away.

Some states have implemented a new role in dentistry  that can provide much needed assistance to  those needing dental work in underserved areas.   The new toothbrush on the block is called a "dental therapist".  

Alaska was the first state in the union to implement the program, imitating  a successful model used in New Zealand for over 90 years.  A very "dentist poor" state,  Alaska concluded that a significant amount of dental work required by a patient could be done by therapists trained in an intensive focused curricula so they could do simple fillings, stainless steel crowns, and uncomplicated extractions. [7] (Dentists still have to do things like root canals, extractions, and all the more advanced work). Therapists are paid about half what dentists are.[8]   

So far Alaska and Minnesota[9] have allowed Dental Therapists to practice under the supervision of a dentist, much like a Nurse Practitioner or Physicians Assistant performs  under the supervision of a doctor.  Maine just started their program, and New Mexico has legislation pending.[10]  Many other states are considering such programs.

From a political point of view, this poses a real opportunity for legislative "across the aisle" co-operation.  For those who think taxes (including those to support heath care for the poor) are too high, and that America's political agenda should be paying attention to creating jobs, the use of dental therapists  offers both a way to increasing the treated patients' chances of joining the workforce make existing  Medicaid spending help many more people.   And for those who think we have a moral obligation to provide basic healthcare  for all, and that government should provide that safety net, the use of dental therapists extends the safety net by making more trained caregivers available.

North Carolina ranks 47th in the nation for dentists per citizen,[11] and the 12 highest poverty rate (18%) in the country.[12]  By imitating other states which have shown the way, we have a huge opportunity to solve a statewide problem in a way that meets the needs of the political left and right. 


[7] Personal Communication  Mr. Lowell Dempsey, Senior Communications Coordinator for Health Policy, Burness  Communications (consulting firm engaged in this issue with W.K. Kellogg Foundation)

[8] Personal Communication  Mr. Lowell Dempsey, Senior Communications Coordinator for Health Policy, Burness  Communications (consulting firm engaged in this issue with W.K. Kellogg Foundation).

[10] personal communication Ms. Carrie Billy, American Indian Higher Education Consortia (AIHEC.ORG)

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