• Yup–Romney was right

    …when he said: “What I would do if I were a Democrat running four years from now, I’d say, you know what, dental care will be included in Obamcare.

    Oral health continues to pose significant access and public health concerns. I’ve worked with various disadvantaged and low-income populations. So many people have obvious dental problems that create broader health problems, are quite painful, and are often stigmatizing in people’s everyday lives.

    Aside from basic access issues, oral health care is a huge missed opportunity for broader public health. To take one example, most adults who report that they face individual HIV risks and yet have not been tested have recently visited a dentist. Many of these at-risk young adults have seen no other health care provider. The dental setting is a largely untapped context to diagnose hypertension and other conditions. Particularly with the emergence of improved oral diagnostics for HIV, diabetes, and various other conditions, we can do better.

    A 2011 Institute of Medicine report outlines useful responses to these policy failures. Improved training would improve the capacity of dentists and other oral health professionals to serve vulnerable populations. Federally Qualified Health Centers provide particularly important services. Their capacity to provide dental services could be expanded.

    We might also reconsider the multidisciplinary character of the oral health care workforce. Licensure requirements and reimbursement practices should be revisited to see which services could be economically and effectively provided by non-dentists in dentists’ offices or in other settings.

    One basic problem is dental care’s segregated financing through plans that demarcate specific boundaries from medical care. The Affordable Care Act is embarrassingly silent about oral health. (Just do a word search on the word “dentist.”) Some help was provided to children. ACA included some provisions for the dental work force. Most importantly, FQHCs received significant support. There’s virtually nothing to improve adult access, to improve dental delivery systems, to improve reimbursement for evidence-based clinical dental services. Little public attention has been paid to whether and how dental plans should participate in health insurance exchanges.

    We also ask too little of the dental profession itself, which remains ambivalent about its own involvement in public insurance programs. At times, the profession also adopts a guild-like protectionist stance against involvement of others in providing oral health. Even in basic matters such as smoking cessation, many dentists report that they are poorly-equipped to deliver basic preventive services. Dental insurers could provide better coverage for these services, which some plans are now exploring.

    This issue hits home for me, particularly as I see state Medicaid programs retrench to limit access to adult dental services.

    When my intellectually disabled brother-in-law Vincent moved into our house eight years ago, he hadn’t had a teeth cleaning in years. So we scheduled an appointment with our family dentist. We knew we needed to prepare him for it. So my two daughters, then ages 8 and 10, read him a picture book about going to the dentist.

    When the dentist donned her mask, he smiled and said: “Like Hannah said,” The dentist scraped off layers of plaque. He was a fantastic patient; this couldn’t have been a lot of fun. Fortunately, his underlying oral health was good. That’s a sweet memory, for many reasons.

    We’ve had various challenges finding a good dentist through the Medicaid program.  One day recently, Vincent announced that he and his housemates had all been to the dentist. My wife looked quizzical and asked Vincent to open his mouth. The dentist had barely cleaned Vinnie’s teeth. The guy had made a cursory effort and then just prescribed a prophylactic antibiotic for gum disease.

    Since then, Illinois became one of the many states—including many traditionally liberal ones–that have retrenched coverage or consigned adult dental coverage to an emergency-only program.

    Romney is right. I only hope that Democrats take his advice.

    Postscript: For more, see Sarah Kliff here.

    • “the emergence of improved oral diagnostics for HIV”

      Is there a reason why this isn’t more widely utilized? Alternatively, am I unaware of how widely utilized this is? There are papers going back to the beginning of PCR showing that viral RNA (or proviral DNA) in saliva strongly correlates with serum viral load. PCR has improved tremendously since then; there’s also a bunch of relevant sequencing opportunities. Maybe as a diagnostic this would have a higher false negative rate than antibody tests, making it a bad idea in a wealthy nation with a low infection rate… but it seems like it would be a very good approach in poorer nations with higher infection densities. Has there been any attempt to widely collect salivary DNA samples (say, anonymously via collecting drinking straws) and use an amplification or sequencing method to track the epidemic?

      I can see how this would present an education/stigma problem — difficult to educate people that detectable salivary virus/antibody/RNA/DNA doesn’t necessarily imply transmittable salivary virus.

    • We are examining these issues. Our study team presented some results at APHA examining insurer, dentist, and patient perspectives on such screening. Many barriers to HIV screening in dental setting. But progress will be made, especially in public health settings.

    • FWIW, Japan covers dental care under its universal insurance system. The patient pays 30% of fees, but those fees are strictly limited so out of pocket expenses are tiny. I just had a crown on a wisdom tooth redone (including re-cleaning out the root canal), and while it took 4 or 5 visits, the most expensive one was US$25, the others were all about US$12 or so.

      This really is a Joe Biden class “big f-ing deal” for the patient. One can get the treatment one needs without worrying about whether you can afford it or not.

    • A compounding factor is that many developmentally disabled people have facial dysmorphia, making dental care harder. Even when a developmentally disabled person doesn’t have facial dysmorphia, they are unlikely to have had orthodontia and it’s harder to effectively clean teeth through brushing if they are not even.