The Disparity Cavity by benbenzhou


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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,

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

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

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

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

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

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.
                                              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

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

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

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


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