Dental Health and Problem
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The Disparity Cavity Most of us brush and floss our teeth and Oral health means being free of have regular dental check-ups; but disease. In a very real sense, the otherwise, we don’t pay much attention condition of the mouth mirrors the to our gums and teeth unless there’s a condition of the body. But good oral problem. Maybe that’s why oral health health also has an undeniable impact on gets so little attention in debates about well-being, because the way your mouth health care coverage. It’s common feels and looks affects how you eat and knowledge that 43 million Americans speak, how you smile, how you interact have no private health insurance, but with other people, whether you sleep how many know more than 108 million comfortably through the night, even have no private dental insurance—or whether you can make it through a day why it is easily overlooked when we at work or school without being bothered have other health worries or run out of by pain in the mouth. time or money. Most of us take good oral health, and But oral health deserves better, for oral the benefits it brings, for granted but, health should be a priority for all of us. points out Dr. Raul Garcia of the Boston At the moment, it is a priority only for the University School of Dental Medicine, people who don’t have it. Unlike medical "to a huge number of people who are care, which most people use only when poor, ethnic minorities, people with they are sick, good dental care is always physical and mental disabilities, dental needed because good oral health is problems can be really important." essential to good overall health. Missing and unfilled teeth mean pain, loss of sleep, poor performance, low As the nation’s premier nonprofit self-esteem, and difficulty in getting and organization dedicated to improving oral keeping a job. health, Oral Health America has initiated a 10-year Campaign for Oral Health Though the full impact is impossible to Parity to make oral health a priority for document, dental problems do affect everyone and increase access to care work and school. A survey conducted in for the 22.5 million Americans who want 1989 showed that children missed but cannot obtain oral health care. An nearly 52 million hours of school, or an important goal in this first year of the average of 1.17 hours per child, campaign will be to help draw national because of dental treatment and attention to the Surgeon General’s problems. That same year, more than Report on Oral Health and sustain 164 million work hours were lost, an attention to the need to address the oral average of 1.48 hours per worker. health disparities identified in that report. Very young children with severe dental This paper lays out some of the reasons problems may not grow normally and Oral Health America has taken on this show serious behavior and attention challenge and examines some of the problems. When their teeth are fixed, obstacles that must be overcome if the they catch up with the growth curves— goal of parity in dental care is to be met. which suggests painful teeth and eating problems had caused malnutrition—and Why Does Oral Health Matter? behavior and learning improve dramatically, simply because they sleep Oral health is more than clean, white better, eat better and are in better teeth, filled cavities, and healthy gums. overall shape to learn and play. Some oral health problems are obvious. that can be fatal if not recognized and Dental and craniofacial diseases and treated swiftly. disorders are among the nation’s most common health problems, and tooth For years, dentists have premedicated decay is the most common and the most patients with heart valve problems or preventable disease in children. Birth artificial parts because of the risk of defects, such as cleft lip and palate infection. Beyond that, neither dentists, occur in one in every 525 to 714 live nor physicians for that matter, have paid births. Injuries to the head and face much attention to the question of how account for some 20 million emergency the condition of the mouth might affect room visits each year. And treatments the rest of the body. A number of recent used for 1.2 million cancer patients each studies, though, suggest there may be year can cause painful ulcers in the links—nothing as definitive as cause mouth, rampant caries, inflammation, and effect, yet—between gum disease infection and dry mouth. and conditions such as heart disease, stroke, diabetes and premature delivery. Beyond the obvious problems, some researchers consider the mouth "the The idea that there might be an laboratory of the body," for its tissues association between dental disease and reflect signs and symptoms of other heart disease and strokes gets support problems. An examination of the mouth, from animal and test tube studies that for instance, can detect early signs of show the same organism that causes such disparate problems as diabetes, most gum disease produces substances bone and joint disease, and cancer. known to cause inflammation in blood Sores and ulcerations can indicate a vessels and blood clotting. Other different set of problems, such as circumstantial evidence also suggests a herpes, mononucleosis or HIV infection. link since a number of chronic infections with organisms not found in the mouth In children, an examination of the teeth are known to increase the risk. and mouth can detect such signs of abuse and neglect as missing and Most human studies of heart disease fractured teeth; oral bruises and cuts; and stroke have not looked for this link, and other head, neck, and mouth and those that have included dental injuries. An estimated 2.7 million cases health usually do not consider smoking, of neglect and abuse are reported each high cholesterol, obesity and other year. A dental exam also picks up poor known risk factors, or have relied on nutrition and hygiene, growth and self-reports of dental problems, not a development problems, improper jaw professional assessment. "Even so, a lot alignment, and oral tumors. of studies show an association linking the two," explains Dr. Garcia whose Literally hundreds of different kinds of long-term study of veterans in the bacteria and other microorganisms live Boston area found those who had gum in the mouth. Their presence is an disease 35 years ago have two to three important reason to maintain good oral times the risk for heart disease and hygiene, for some cause infection and stroke. Another long-term study, this disease. If they spread into the blood one involving health professionals, stream some organisms can cause found an association between gum bacterial endocarditis, an inflammation disease, heart disease, and people who of the lining of the heart and heart also lost their teeth. valves, or blood poisoning, a problem But an association is different from cause and effect. A well-controlled, 2 long-term study to determine if the and low birth weight babies, we can control of gum infection with antibiotics have a major public health impact with a would reduce the risk of heart disease minor investment in dental care." and stroke might answer that question. The Care Gap Diabetes is another common disease associated with infections of the mouth. Overall, American teeth are in better For years it has been recognized that shape than they ever have been. diabetes predisposes to all types of Fluoridation of water supplies has bacterial infection, including infections in reduced the amount of tooth decay by the mouth, and that infections hamper a about 65 percent over the past decades, patient’s ability to control blood sugar and a new sealant technique can protect levels. What has not been clear is what vulnerable teeth surfaces from decay. role gum infections play, though patients But problems remain. As dental disease with severe periodontal disease do have declined, it also became more trouble maintaining blood sugar levels. concentrated in a subset of the Recent work suggests treating and population. Not all water supplies are controlling gum disease means that treated with fluorides. Currently, some diabetic patients need less insulin. 18,000 community water supplies, which serve about 40 million children, are not Pregnant women are advised to have fluoridated. And only 20 percent of the regular dental care since oral infections nation’s children have plastic sealants produce high levels of substances, on vulnerable teeth. That 20 percent known as prostaglandin, which can does not include most of the low-income induce premature labor and the delivery and minority children who have the of low birth weight babies. One study greatest problem with tooth decay. found the risk of premature delivery and a low birth weight baby was seven times Other indicators, too, suggest an implicit greater in women with severe gum rationing of dental care. The success disease. with preventive measures has not translated to those who have dental The possible impact of gum infections problems. Statistics show the on miscarriage or even on fertility is not percentage of Americans who get clear, but one ongoing study is cavities has dropped, but also show a identifying pregnant women at risk for decline in the percentage of those who small babies to see if cleaning their do get cavities and have them repaired. teeth and controlling oral infection will For that group, the problem is getting cut the risk of premature delivery. Many worse. What studies have been done of these women have other risks for show that poor children have about five premature delivery as well, including times more unfilled, decayed teeth than smoking and poor nutrition. children above 300 percent of the poverty line. The new attention to possible links between oral health and problems The percentage of teeth that have been elsewhere in the body has ramifications decayed and filled further document a that go beyond health. "There’s care gap, for there’s a four-fold increasing evidence that controlling difference between high- and low- mouth problems can have a major income groups. Among children, the impact on physical well-being and most recent National Health lowering the costs of care," comments Examination and Nutrition Survey found Dr. Garcia. "If keeping mouths clean can that Mexican and African American lower the risk of diabetes, heart disease 3 children had twice the number of dental decay, and by the time they untreated cavities as white children. For graduate from high school, it has risen adults in low-income groups, half of to 84 percent. By the time they reach teeth that have decayed have never the age of 45, more than 99 percent of been filled. This situation has taken a this population has had tooth decay. striking toll, for among low-income people over the age of 35, nearly one- Disparities in oral health care do not third have no teeth. stop with decay. Gingivitis, characterized by tender, puffy gums that Limited studies of dental visits reinforce bleed easily and the first stage of more this suggestion. One such study showed severe periodontal disease, is seen in that for the decade between 1983 and half of high school students; 15 percent 1993, only 35 percent of those 25 and of adult Americans have advanced older in lower income groups had visited periodontal disease and are in danger of a dentist within the past year, compared losing their teeth. In lower with about 60 percent of those above socioeconomic groups, 33 percent of the poverty level. In 1997, a study found people over the age of 35 are that 80 percent of those in higher edentulous. In this category, the income groups had visited a dentist. difference between lowest and highest That means at least twice as many more socioeconomic groups is eight-fold. affluent people get dental care. In another indicator of the gap in care, Looking only at children, two federal Healthy People 2000 reports a marked surveys came up with different answers. disparity in outcome rates for Healthy People 2000—an ongoing oropharyngeal cancer, a disease—in government project that identifies the this country at least—due almost status of specific health variables, then entirely to smoking and the use of sets targets for improvement—reported tobacco products. This is the 10th most that about 73 percent of children were common cancer in men, the 14th in getting dental services, but an analysis women and is more common than such of medical expenditures in 1997 put the better known cancers as leukemia and number at 43 percent. The truth is Hodgkin’s disease. Approximately probably somewhere between the two, 27,000 new cases are diagnosed each notes Dr. Burton Edelstein, director of year, and 8,000 deaths are reported. the Children’s Dental Health Project. Treatment is most successful when cancers are diagnosed early, but in According to the National Institute of terms of survival, only 31 percent of Dental Research, dental caries is the African Americans pass the 5-year most common, preventable disease in mark, while 55 percent of white patients children. Children can avoid cavities do. entirely if given early and proper dental care, but not all children get this A study published in 1998 addressed attention. In 5- to 17-year-old children, disparity in access by trying to identify 80 percent of cavities are found in a people who believed they needed but subgroup of the 25 percent at the lower had not received dental care. This end of the socioeconomic scale. approach identified differences by sex and ages. More than 12 percent of adult Problems start early. Healthy People women, 19 to 64, identified unmet 2000 reports 18 percent of 2 to 4 year dental needs, compared with a national olds have visible tooth decay, and the average of 8.5 percent. At 9.5 percent, numbers keep climbing. More than half unmet dental needs for men also topped of elementary school children have 4 the national average, and were greater better access to medical or surgical than the 5.9 percent reported for care. children or the 3.6 percent for the elderly. Looking only at children, a recently published analysis of the National When race and ethnicity were Health Interview Survey showed 7.3 considered, results were comparable for percent of parents thought their children Hispanics, at 7.4 percent, and whites, at had one or more unmet needs. For 73 8.3 percent, but 15 percent of African percent of those children, that unmet Americans reported unmet care needs. need was dental. That means, notes Dr. Other disparities were identified. People Edelstein, that one in every 20 American in fair or poor health were more than children has an unmet dental need. The twice as likely to have unmet dental care need for medical care was runner-up. problems than those who considered their health good or excellent, and Who Does, and Who Does Not, people with chronic health problems Get Care? were even more likely to have unmet needs. No single study answers these questions. But a number of very Geography and education also play a different indicators suggest that the role. Unmet care needs were greatest in number of people who get dental care the South, lowest in the Northeast and has increased in every age group, for Midwest, and slightly higher in both sexes, at all income and households where the head had less educational levels and across the major education. Income, though, was a more racial and ethnic groups. powerful indicator, for 16.4 percent of those below 150 percent of the poverty Such data is encouraging, for it marks level reported unmet care wants progress in efforts to make sure compared with only 6.3 percent of everyone in America gets dental care. families above that level. When But the improvement masks subtle but insurance coverage was considered, the very important problems. Despite the disparity became even greater for 22.6 increase, 100 million Americans don’t percent without insurance reported visit a dentist each year. That 100 unmet needs, compared with slightly million includes many people with less than 6 percent of those with private special dental care needs, including the dental coverage. More than 12 percent elderly, those who live in nursing of Medicaid recipients reported unmet homes, the homeless, disabled wants. populations, and very young children. Further questions revealed that more Of all the special needs groups, the than two-fifths, or 9.3 million Americans, homeless may be the most vulnerable had limited their activities because of and the most difficult to reach. Most dental problems. When these problems don’t have a regular place to brush their were later evaluated, nearly three- teeth or carry a toothbrush, so oral quarters were classified as moderate to hygiene is poor. Since the homeless—a serious, less than a quarter as not population estimated at 2 million people, serious at all. The results, the report’s about 25 percent of them children—also authors concluded, suggest that the have problems with untreated mental populations that would benefit from illness, alcohol and substance abuse, more access to dental care were the domestic violence and access to health same as those that would benefit from care, it follows that they would have 5 serious dental problems, and they do. children with disabilities lose the With no money, no health insurance and coverage they had under Medicaid and, no home, they have trouble finding with it, the guarantee of dental care. At dentists who will care for them, and that point, the cost of care combined even though at least many of the with the fact that few private dental children are eligible for care through offices are equipped to deal with Medicaid, little effort is made to see they disabilities make care even more get care. problematic. Poor overall health and poor nutrition Only a few small studies hint at the complicate the oral health picture. dental care needs of the adults in this Dental problems are 12 times more group, but they suggest needs are likely among the homeless, and these great. For instance, at least a quarter of problems tend to be serious. Slightly those with cerebral palsy have dental more than half of the homeless, 53 problems, 30 percent of those with head percent, have complete sets of teeth in injuries, and 17 percent of the deaf. contrast to 91 percent of the general population; and one survey found that The nation’s growing senior citizen 83 percent had not had their teeth population also is at high risk for dental cleaned in the previous four years. And, problems. The risk is greatest among though 96 percent of homeless children the less able, who fail to get dental care age 5 to 9 were found to require dental for a variety of reasons: unpredictability care, most had never seen a dentist. of illness and energy, the time it takes to get to a dentist, and dependence on The 43 million Americans with physical other people for transportation. And, of or mental disabilities also seem to have course, the cost. Only 15 percent of the higher rates of dental disease than other over-65 population has any kind of segments of the population. Some of dental coverage, so senior citizens with these are due to medical problems or a fixed and limited income tend to give the side effects of medication, some to dental care low priority if they must the disability itself. Proper oral spread their resources to cover drug hygiene—even the task of brushing and and extra medical bills as well as the flossing on a regular basis—is costs of food and shelter. Medicare challenging for many. Moreover, many covers no basic, preventive or dentists are not trained, or are not reconstructive dental services, only willing, to manage complex medical and dental problems related to a medical behavioral problems experienced by problem. many in this group. Many children rely on Medicaid for dental coverage but few An estimated 70 percent of the nation’s states cover dental services for adults 2 million plus nursing home population under Medicaid. Even with Medicaid, has dental problems that include low reimbursement rates often don’t dentures that don’t fit and loss of some permit the kind of care, including or all of their teeth, but most significantly hospitalization and anesthesia, required poor oral hygiene. Many nursing home for treating some disabled patients. patients are not able to brush and floss adequately on their own. Their oral care The need for dental care doesn’t end is provided by untrained, usually with childhood and people with underpaid aides with little incentive or disabilities face even greater problems time to do a proper job. Consequently, when they "graduate" from Medicaid. sore and bleeding gums, oral infection Each year, an estimated 100,000 and decay are frequently seen among 6 nursing home residents. Since costs of space holders for the positioning of adult providing care to these patients are teeth. high, treatment depends on Medicaid eligibility and the kinds of services that The Barriers: Why some may be covered by a state. To make the People Don’t Get Care problem even worse, one study showed that dentists who work in nursing homes The question of why so many people don’t offer a full range of services. Less don’t get regular dental care has no than one-third, for instance, provides easy answer. Since about half the necessary cleaning and scaling. population has no form of dental insurance, cost—whether direct out-of- Young children comprise a different type pocket payments for care or the of high-risk group. Though the American perceived cost of adding dental benefits Society of Pediatric Dentists to existing public and private insurance recommends a first dental exam as programs—is usually cited as the main early as the eruption of the first baby barrier. A number of studies show that, teeth, and certainly by one year, less when financing is available, the poor than one percent of children actually get use dental services at the same rate as this kind of care. The still common the rest of the people. practice of putting infants to bed with a bottle of milk, juice or some sweet liquid Greater insurance coverage is no means that liquid pools around the guarantee more people would receive teeth, where bacteria in dental plaque care, for other barriers exist. About 90 breaks down the carbohydrates in the percent of the nation’s dentists are in liquid, producing acids that attack dental private practice and don’t work in inner enamel and cause decay, a process cities and rural areas where poor and known as "nursing bottle tooth decay." underserved people live. An impending dental manpower shortage and a drop in The fact that nearly one in five the numbers of minority dentists youngsters 2 to 4 years of age have threaten to make this barrier even visible tooth decay documents the need greater. Also, though dental treatment for this early examination. But another for Medicaid-eligible children is important reason comes from the mandated by law, many dentists don’t relatively recent discovery that dental accept Medicaid patients because low caries are infectious and can be reimbursement rates do not cover costs transmitted to infants through the of care and they consider Medicaid, with mother’s saliva—a good reason not to its rules and regulations, an share spoons or toothbrushes. administrative "nightmare." Tests can now detect which children Less easy to document, priorities and have high levels of decay-causing attitudes also keep people from getting bacteria so that disease prevention can or giving care. To most people, other be started at a very early age. Since health conditions seem far more teeth are susceptible to decay as soon important than dental health when time as they erupt, and most children have and money are limited, especially since no dental care during their early years, the link between dental health and untreated disease and early tooth loss is overall health is not widely understood. common—and at least five times more Nor is the fact that medical and dental common among the poor as their more care are different. Everyone needs affluent peers. Even preserving baby regular dental care, though only certain teeth is important, for they serve as groups—the very young and the very 7 old and those with chronic conditions— guarantee care. Other care for those need regular medical care. The belief who have trouble paying is provided by that oral diseases are inevitable also hospital and dental school clinics and by keeps many from preventive care. Some private dentists. A 1997 survey by the cultures simply accept, as a given, that American Dental Association showed the loss of some or all of their teeth is nearly half of all dentists provided some part of life. uncompensated care. The total amount of charitable care is an estimated $2 Who Pays for Care? billion a year, most for the poor and the near poor. The financial barrier to care is considerable. More than 150 million Because dental care for 20 million Americans, 55 percent of the population, Medicaid-eligible children through age have no dental insurance. Studies show 18 is mandated by law and the new that those without private dental Child Health Insurance Program (CHIP) insurance, which, like health insurance, provides dental coverage for an is employer provided, are less likely to additional 4 million low-income children, have seen a dentist recently than those in theory at least, needy children should with insurance. The uninsured tend to be able to get dental care. In practice, a visit a dentist only when they have a majority of poor children still do not problem, so are less likely to have a receive dental care, even though they regular dentist, to use preventive care or are eligible. Despite the legal to have all their dental needs met. One requirement, Congress has never study done in 1989 found that nearly provided enough money to carry out the half of people without private insurance program. "We have a program that didn’t visit a dentist in the prior year, made the promise but didn’t deliver," compared with 28 percent of those with reports Dr. Edelstein. insurance. An estimated 16 million eligible poor Dental care accounts for a minute children do not get dental care, and the portion of the nation’s trillion-dollar main reason is lack of funding. In many health care bill. In 1997, a total of $50.6 states, Medicaid reimbursement rates billion was spent for dental care and for dental care are too low to even cover nearly half, or 47 percent, was paid the costs of care, so many dentists can’t directly by patients. The public share afford to take Medicaid patients. States was a mere 4.4 percent, most of that the that have raised reimbursement rates or $2 billion federal and state contributions offered other incentives have found for Medicaid recipients—and most of more dentists willing to participate. "The that for children. Other government core problem is the tacit acceptance of funding, while limited, comes through this situation by the general public," Medicare—though almost all of that is in says Dr. Howard Bailit of the University managed care plans—Head Start and of Connecticut Health Center. "Because several programs operated through the Medicaid is a program for poor people Health Resources and Services and because most people value dental Administration as well as "safety-net" care less than other medical services, services such as school-based clinics there appears to be little public support and community health centers. to change this situation." With so many dentists in private Dentists cite other problems with practice, the mere existence of these Medicaid. Payment is slow and limited public programs does not unpredictable and, to the dentists at 8 least, denials sometimes seem arbitrary. Cultural differences work both ways. Even routine care may require prior Dentists may lack the sensitivity and authorization. Administrative understanding of different cultures and requirements and paperwork needed to fail to make sufficient accommodation comply with Medicaid rules and for problems Medicaid patients confront regulations, which vary by state, are simply to get care. Suggestions offered also cited as reasons for not accepting at a conference devoted to improving Medicaid patients. Some refuse, too, the access of Medicaid children included because they find Medicaid patients— developing systems for transportation many confronted with day care and and child care, educating parents about transportation problems—often fail to the importance of oral health and how keep appointments. they can help, appropriate behavior in an office and the importance of keeping Distribution of dentists is also a problem. appointments—strategies that could Though studies suggest people feel ease problems for both parents and more comfortable with a practitioner of dentists. their own race, the number of minority dentists is not sufficient to meet the If children fare poorly under Medicaid, needs of the population. Few dentists adults have an even worse time. Only practice in inner cities or rural areas, 32 states cover any kind of dental care where the needs are greatest. For for Medicaid-eligible adults, and that is whatever reasons, the result is the mostly for emergency care. Rules often same: children covered by Medicaid stipulate the least costly treatment, often cannot find a dentist who will treat which, in most cases, means simply them. A 1977 survey found that almost pulling an affected tooth. 30 percent of dentists had one or more Medicaid patients, but that less than half In an effort to understand why many of them saw 10 beneficiaries in the Medicaid beneficiaries do not seek month of the survey. dental care, even when it is covered and dentists will accept them, a study in the The problems don’t stop with the state of Washington found a lack of dentists. Many parents do not realize information about coverage was the their child may be eligible for greatest obstacle, followed by a government-funded programs and do perception that dentists who accept not understand how to use the programs Medicaid are not available and the or even how to find a dentist. Dentists recognition that the need for preventive often worry about how to overcome dental care was not sufficient to prompt what they see as "cultural differences" recipients to find out about coverage or when parents accept the loss of teeth as locate a dentist. an inevitable part of life because these parents don’t understand the need for Who Will Provide Care? regular brushing and dental visits and only seek care when there is a problem. The current access problems will only Some fail to understand that missed become more acute in the future as the appointments are costly and disruptive supply of dental manpower declines. to dentists, and because of language or Many have worried that dental educational differences don’t always education is approaching a crisis with follow instructions for care or dietary declines in applicants as well as changes. graduates. The decline started when dental schools reduced their enrollment by about 30 percent in the 1980s and 9 went from about 5,200 to the current of female dentists may also reduce the 4,000 graduates a year. During that supply of dental services because same time, six dental schools have women tend to work fewer hours, closed and others face financial especially when they have young difficulties. Faculty salaries have not children. In the next year, more dentists kept pace with dental income, which will leave the profession due to makes practice far more attractive than retirement and death than graduate from academic dentistry or dental research. dental school, a trend that is expected to increase as the workforce ages even Especially worrisome in terms of more. One projection shows that in 20 providing care is the decline in the past years, the relative number of dentists few years in both minority applicants will decline by 10 percent, from the and enrollments, a problem that current 58 per 100,000 to less than 52. threatens to make the access problem in already underserved communities Manpower concerns extend beyond even greater than it is today. In 1996, clinical practice. Academic dentistry and African Americans made up 12 percent research also suffer. Between 300 and of the population, while African 400 dental teaching positions are not Americans accounted for only 2.2 filled, and probably will remain empty, percent of the dental workforce and leading to what Dr. Walter Cohen, Hispanics, with 10.7 percent of the former dean at the University of population, had 2.8 percent of the dental Pennsylvania School of Dentistry, calls workforce. Whites, who comprise 73.2 a "crisis in dental education." Without percent of the general population, good teachers, he worries, "the quality accounted for 87.9 percent of the of the educational piece will decline." nation’s dentists. Compounding the teaching problem, the Journal of the American Dental Native Americans, with a population of Association reported that federal 2.4 million spread through 560 support for dental education has fallen reservations, many isolated in the west, sharply, from 27.6 percent in 1997 to confront the most serious manpower less than 1 percent in 1997. problem, with a ratio of one Native American dentist for every 35,000 in the Dental research is also suffering, with a Native American population. Among growing list of important research issues non-Native Americans, the ratio is about that cannot be studied because of a one dentist to 900 people. With the short supply of qualified researchers. exception of Asian Americans, whose One reason both academic dentistry numbers have increased, dental and dental research are in such dire enrollments for all racial groups— straits is money. The average dental including White—have declined over the graduate comes with a debt of past few years. $100,000, but a debt as high as $150,000 is not uncommon. Such an At the other end is an aging workforce. amount is almost impossible to repay on The average dentist is now 50 years old. an academic or research salary, which Many are retiring and many are cutting forces young graduates into private back on the number of hours they practice. Congress has looked at practice. Several years ago, dentists solutions such as debt forgiveness for averaged 42 hours a week; now the those who go into research, but so far average dentist works 37 hours and the situation remains unresolved. nearly 30 percent work 30 hours or less each week. An increase in the number 10 In 1995, Dental Education at the care," worries Dr. Bailit. "There’s not a Crossroads, a report from the Institute of constituency out there screaming for it." Medicine, addressed the issues that still Without that constituency, and the votes confront dental education today. Among it could carry, the elected health policy its recommendations, the report urged makers of this nation do not consider more support for dental education and good oral health a high-priority issue. "closer integration" of medical and dental curricula. The proposal would That could change as the public have eased the teaching problem, at becomes more aware of the strong link least for the basic and behavioral between good oral health and good sciences, brought the two professions overall health. The release of the closer together and eased some of the Surgeon General’s groundbreaking financial pressures on both sides. Five report on Oral Health and the ambitious years later, little has changed: medicine goals for reducing disparities in care that and dentistry remain separate. are included in Healthy People 2010, the government’s health goals for the What Can Be Done? nation of the next decade, should push the issue to the forefront of public Most of the problems confronting dental attention. care today could be overcome by putting more money into the system, more money for better and wider coverage—public and private—more money for dental education, more money for public education. But money is not the only answer. Developing the systems to deliver care to underserved areas and those with special dental needs is also essential. Some of the solutions are self-evident. Dr. Bailit, for instance, thinks "a relative modest increase" of $3 billion in the $152 billion Medicaid budget would provide basic dental services for the entire Medicaid-eligible population and would make a significant difference in the access problem—as long as program administration improves and reimbursement levels increase. None of this will happen until the public demands it, but there is no organized and vocal constituency for oral health. Even senior citizens have not lobbied for dental coverage through Medicare, though the elderly are at risk for serious, and expensive, dental problems and only 15 percent have dental insurance. "The general societal view is that dental care is not as important as medical 11