Commentary: The painful truth about oral health
by Dushanka V. Kleinman DDS, MScD, associate dean and professor
The time has come to integrate dental care into overall health care. The 5/14/2017 Washington Post front page article, “The Painful Truth About Teeth” by Mary Jordon and Kevin Sullivan, shines a light on a preventable tragedy, and a major gap in our U.S. health system. We have separated the mouth from the rest of the body for too long and our population is suffering. This tragedy will only get worse without overt action.
We know what needs to be done, and what we know must be shared widely. We know how to prevent the most common dental diseases, tooth decay and gum disease. We know that oral health care focused on preventive strategies is needed throughout life, and begins during prenatal care. We know that untreated oral diseases have serious and devastating adverse health effects, curb critical daily functions (eating, speaking) and social well-being, contribute to time lost from work and school, and limit employment options. We know there is sufficient evidence of associations between chronic oral infections and diabetes, heart and lung diseases and stroke. We also know that individuals with diabetes, coronary disease and cerebrovascular stroke who receive oral health care have lower costs of medical care, based on several studies by health insurance companies and the American Dental Association.
Vulnerable populations are most at risk. We have seen the benefits from increased investments in children’s dental benefits in Medicaid, and know it can make a difference. However, the majority of states provide limited to no Medicaid dental benefits for adults. In our National Capital Region, Virginia and District of Columbia provide limited dental benefits, and Maryland provides emergency-only dental services for adults. For older adults - and this may come as a surprise to many -Medicare does not include dental benefits.
The most recent Mission of Mercy was held in Salisbury, Maryland. In Maryland:
- 46% of low-income adults are without a dentist, dental hygienist, or dental clinic visit in the past year (compared with 30% for all adults),
- 16% of low-income adults ages 18-64 have lost six or more teeth because of tooth decay, infection, or gum disease (9% for all adults),
- total expenditures for outpatient Emergency Department (ED) dental visits continue to rise (from $15.3M in 2010 to $21.5M in 2015), and a study of 2013 ED dental visits reveals that 47% of patients are back within 30 days.
Lack of oral health care to prevent and manage medical conditions adds another disease burden, and costs, to complex and challenged patients, often older adults. The devastating opioid addiction crisis, stemming in part from an increase in opioid prescriptions, commonly provided to patients frequenting EDs for their dental infections, is yet another reason to integrate oral health.
Examples of how oral health can be integrated into overall healthcare exist. The Marshfield Clinic in Wisconsin, a large physician group practice, has an integrated medical/dental EHR that includes health conditions, prescribed medications, appointments, and decision support tools to help physicians and dentists coordinate care. HRSA’s Integration of Oral Health and Primary Care Practice initiative provides recommendations to integrate oral health across health care professionals with a focus on the safety net community primary care professionals, such as nurse practitioners, nurse midwives, physicians and physician assistants. Use of mid-level dental providers can further extend care.
In his 2000 report, Oral Health in America, Surgeon General David Satcher called oral diseases a “silent epidemic,” noted “the profound and consequential disparities,” and called for a coordinated effort to achieve oral health for all. Seventeen years later we see a widening of the gap between those who can afford care and those without such resources. Yes, the issues that contribute to this gap are complex; but waiting is not an option.
Enhancing oral health literacy and including dental benefits in public and private health insurance would be a start. It should be common knowledge that the first line of defense to prevent tooth decay is to drink fluoridated tap water, dental care for pregnant women is safe and important for their and their baby’s health, and that treatment of gum infections in patients with diabetes enhances glycemic control. Oral health, like behavioral health, is an essential part of a quality team-based delivery model system, and inclusion of oral health care could contribute to reduced avoidable utilization of health services, enhanced quality of care (and quality of life) and to reduced costs.
As a former Chief Dental Officer of the U.S. Public Health Service Commissioned Corps, it is painful to see that Missions of Mercy have become routine, because while they provide critical stop-gap care, they are emblematic of how we treat oral health as an afterthought. Integrating dental care into overall health care is long overdue.