• Dental care: a missing link in public health and health policy

    I spent Friday on the road, working on a project connected with dental care. I’ve been doing other research examining the potential role of the dental care setting in public health and preventive care. Oral health continues to be a major missed opportunity in both public health and health reform.

    As I’ve noted before, the dental care setting provides an untapped opportunity for needed screening and clinical prevention interventions. I and my colleagues Lisa Metsch and Stephen Abel explored one such opportunity in the American Journal of Public Health. We examined the population of Americans who report that (a) they face significant HIV risks, (b) have not been tested for HIV. More than 70 percent of these men and women had recently been to a dentist, even though many are not getting any other medical care.

    In 2006, the Centers for Disease Control and Prevention promulgated guidelines for opt-out testing. In some ways, dental care is an excellent setting for opt-out testing of this sort. Particularly in the context of dental public health facilities, this deserves serious consideration.  An oral HIV screening test would take about 20 minutes and would not be particularly costly.

    Of course HIV testing is a very heavy lift within the dental care setting. Unfortunately, neither CDC nor anyone else has prepared patients or providers for the idea that dentists might perform such testing. If you watch prime-time TV, you’ll see direct-to-consumer advertisements in which an attractive spokesperson explains the benefits of Lipitor or Viagra, with the follow-up message: “Ask your doctor about our product.” The message is action-oriented, and organizationally specific. Patients know what to ask about. Doctors know the questions are coming.

    Far less often, you might see a public service announcement about HIV testing. Most of these commercials say: “Get tested.” That’s important, but it’s also pretty nonspecific. The public service announcements rarely say: “Ask your doctor for an HIV test.” They almost never say: “Your primary care doctor, the staff at your local ER, or your dentist might offer you an HIV test. That’s a little embarrassing, but this is what we all need to do.” In the absence of such public education and advocacy, it’s weirder than it needs to be to embed HIV screening within routine medical and dental care, which is where it needs to be. There is less impetus than there should be to change the culture of dental practice and care to embrace these issues.

    We’ll have more to say about our dental research based on subsequent survey research we have performed with patients, dentists, and insurers. Some of this work concerns HIV testing. Other work concerns hypertension, diabetes, and smoking cessation. More imaginative care practices and improved dental insurance coverage of preventive services and diagnostic screening might make a big difference.

    Basic access wouldn’t hurt, either. More than a decade ago, Surgeon General David Satcher released a report, Oral Health in America, which noted a “silent epidemic” of oral disease among many populations of Americans at economic, social, or health risk. The report lamented an inadequate dental public health infrastructure which cannot address these widespread needs. Some progress has been made, especially among children. More needs to be done. There is little political will to do it.

    The Affordable Care Act largely sidestepped dental care. Pediatric dental care is an essential health benefit. Adult dental care is rather conspicuously ignored. Indeed if you do a global search on the word “dental,” you will find surprisingly few hits in the entire bill.  Medicare does little with dentistry, though Medicare Advantage plans often provide coverage. Dental benefits are often (though not always) covered through state Medicaid programs. Even when Medicaid covers these benefits, private dentists are generally unenthusiastic about treating Medicaid patients. At one level, such reluctance is understandable. Medicaid pays low reimbursement rates; Medicaid patients can create various practical difficulties. Many dentists would rather not bother.

    Basic dental care is not particularly costly. Yet millions of Americans needlessly lose teeth. Millions suffer oral infections that sometimes bring significant health consequences. Millions simply experience unpleasant and painful oral disease that could be readily treated.

    Largely due to the guild interests and preferences of the dental profession itself, this domain of human health has largely been kept separate from the rest of American medical care. Moreover, the profession resists efforts to license lower-skill, lower-wage mid-level professionals who could provide valuable and cost-effective basic oral health care. We should do better.

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    • In Massachusetts Medicaid (MassHealth/”Romneycare”), the only dental care covered is extractions. I cannot count how many of my (counseling) clients were unable to afford cleanings, fillings, etc. and ended up losing several or all teeth.

      With my people, it’s often too late for major preventive care, especially with users of certain drugs. But they didn’t have the care as children, either; and if they’re on MassHealth, neither do their own kids.