Dental Health Care

The organization and provision of services, including health education and promotion, to meet the preventive, acute, chronic and long-term oral health needs of a population. This first section of this article provides a brief introduction to dental disease and its impact on the U.S. population. It also contains a short discussion of critical preventive measures that serve to minimize dental disease. The second section presents a profile of the dental profession. The third section addresses access to dental care, with an emphasis on the unique problems faced by rural residents, ranging from the affordability of care to the recruitment of dentists to remote communities.

Dental Disease and Prevention

Of the many diseases humans face, those of the oral cavity are undoubtedly the most pervasive. Chief among these oral health problems are dental caries (cavities), periodontal disease (gum disease), oral cancers, and structural and functional problems that involve the teeth, mouth, head, neck and skull. Dental trauma, such as that incurred from accidents and sports injuries, and genetically related problems, can also compromise oral health.

It is not unreasonable to presume that children suffer the most from dental disease since, left untreated, the effects are with them the rest of their lives. To look at statistics on just one disease: dental caries is five times more common among children than asthma and seven times more common than hay fever. The Surgeon General’s report on oral health in America, published in 2000, notes that poor children are twice as likely to suffer from dental caries as those who are more affluent, and they are far less likely to receive treatment. According to the same report, more than 51 million school hours are lost due to oral health problems. The impact on adults is comparable: in 1989, over 164 million work hours were lost due to oral health problems. Minority persons, low income, and service workers were the hardest hit. Dental caries has declined since the 1940s, but nearly half of all school age children still have some caries. On the average, in persons age 40 and older, more than 30 tooth surfaces are affected by caries.

Diseases of the periodontal tissue affect nearly half of the adult population, and while gains have been made in recent years, approximately 36 percent of persons over 65 have lost all of their natural teeth. Oral cancers, often associated with tobacco use, remain a significant health problem and can lead to disfigurement and, in some cases, death.

Older Americans, in particular, represent a growing challenge to the dental profession. As overall health status improves, people live longer and have increased vulnerability to dental disease. Root caries, the development of dental cavities on the roots of teeth, was virtually unheard of in the 1950s, but is now seen with increasing frequency in dental offices. The administration of multiple medications to the elderly, a common occurrence, often precipitates a condition known as “drymouth” which, in turn, increases the risk of root caries and other oral health problems.

In general, dental health is not sharply different between urban and rural areas, but there are several differences which can be noted. Edentulism, or lack of teeth, is much more common among persons over 65 in rural areas, for example. Frequency of dental visits tends to be lower among the 18- to 64-year-old age groups from rural America, and rural counties are more prone to have shortages of dentists than are urbanized counties. These last differences are access issues, but contribute to higher levels of dental disease in the affected populations.

Funding shortages over the past several decades have severely restricted oral health surveys and other public health research efforts, but there is every indication that dental disease (predominately caries and periodontal disease) continues to compromise the health of the American people.

With proper oral hygiene (regular and correct brushing and flossing), healthy eating behaviors and professional care, the vast majority of dental health problems can be prevented or managed effectively. Virtually every dental office provides educational materials and instructions to help patients understand the importance of proper hygiene and diet. The American Dental Association also makes available a great deal of information on these and dozens of other consumer topics, including mouthguards and accident prevention.

In addition to oral hygiene and healthy dietary practices, fluoridated toothpastes, mouthwashes and dietary supplements have been extremely helpful in reducing dental caries. Topical sealants and fluoride varnishes further reduce the risk of caries in young children. Many scientific and technical advances have enabled the dental profession to make significant progress in combating dental disease over the past 50 years, but without doubt, the most notable of these has been the fluoridation of community water supplies, an action hailed as one of the top 10 public health achievements in history. Community water supplies can be treated for roughly 50 cents in towns over 20,000 people, and towns of less than 5,000 can do so for about $3.00 (in 1995 dollars). (Fluoride supplements are available for those on well-water sources.) Since community water fluoridation began in 1945, untold millions of dollars have been saved and much pain and suffering have been avoided. The saving in dental services has consistently been found to outweigh the cost.

The Dental Profession

More than a quarter million trained professionals provide dental services to the public. In addition to dentists, dental hygienists, several types of dental assistants and dental laboratory technicians apply specific skills and training in health education and clinical dental care. In Alaska and some other states, new types of care providers (sometimes called “dental therapists”) have been deployed or are being considered in an effort to address particular dental workforce and dental care access problems. These “mid-level” providers offer a potential way of reducing dental care costs, of expanding the workforce rapidly, and have been used for as long as 85 years in other countries, most notably New Zealand.

According to the American Dental Association and the Bureau of Labor Statistics, in 2006, about 85 percent of dentists were in general practice. Typically, general practice dentists perform a full range of services for an average of 4,000 patients per year. Of the dental specialists, nearly half are either orthodontists (dentists who treat tooth and jaw alignment disorders) or oral and maxillofacial surgeons (dentists who specialize in surgical procedures involving the head, neck, teeth, jaws and oral cavity). Other specialists include pediatric dentists (who treat children), periodontists (who treat diseases of the gums and other supporting tissues), prosthodontists (who focus on the replacement of missing teeth), endodontists (who treat disorders involving the dental pulp), and oral pathologists (who work with oral cancers, genetic disorders, and head, neck and oral disease identification). Other dentists focus on the elderly, forensic dentistry, or implanting damaged and missing teeth. Although not technically a specialty, many dentists limit their practices to “cosmetic dentistry.” Such dentistry rarely addresses functional or disease problems, but instead offers patients aesthetic adjustments and “whiter smiles.”

Public health dentists address the needs of broad segments of the public and communities. Some are directly involved in delivering care; others work in research and administrative positions. They study dental disease patterns, dental care delivery and access problems. Their chief concern is with disease prevention and ensuring that care is available to those in need.

The majority of clinical providers are in private practices, ranging in size and complexity from single dentist, solo practices to large health maintenance organizations or other managed-care practices which may employ dozens of dentists at multiple locations. In the public sector, dental care is provided through the Indian Health Service, the U.S. Bureau of Prisons, the various branches of the military and Veterans’ Affairs, and the National Health Service Corps. In some cases, particularly in the case of tribal nations and with the National Health Service Corps, public-private partnerships may be involved. Although well over half of all dentists practice in major metropolitan areas and large cities, many are located in smaller communities scattered throughout rural America.

Approximately 75 percent of U.S. dentists are in solo practice. The average 2004 income of general practitioners who own practices was $185,940, while specialists averaged $315,160, according to the American Dental Association. The vast majority of dentists are White males, but dental schools currently have high enrollments of females (often in the vicinity of 50 percent) and are aggressively recruiting students from underrepresented ethnic communities. By expanding career opportunities to these groups, it is believed that increased numbers of minority and female dentists will also help open the dental care system to persons who might otherwise be reluctant to avail themselves of care.

Access to Dental Care

Access to health care is perhaps the greatest challenge facing policy makers as United States moves into the twenty-first century. In most states, dental care is a major component of that debate. Access is a function of many interrelated factors. Briefly, access involves affordability, accessibility, availability and acceptability.

“Affordability” quite simply refers to the ability to pay for health care services. Not surprisingly, financial issues tend to receive the most attention in public debates primarily because the cost to treat dental disease is substantial. In the U.S., where dental services are arguably the best in the world, expenditures for dental care topped $80 billion in 2004. Despite scientific advances, cost control measures and improved health status, dental care costs are expected to continue to escalate in the foreseeable future. These expenditures would be much higher were it not for numerous scientific and technical advances in dentistry over the past half century. Educational, scientific and technical discoveries had significant impacts on virtually all aspects of dental disease and oral health behaviors.

Dental insurance, particularly private dental insurance, is one of the strongest predictors of dental care utilization, but it is less likely to be available to rural residents. Public insurance programs, most notably Medicaid, have been fraught with inadequate funding, and administrative and professional reimbursement issues. “Accessibility” speaks to the question of whether patients are able to get to a provider without undergoing undue hardship. Thus, the goal is that providers be located within a reasonable geographic “space,” including distance and modes of transportation (roadways, public transportation, etc.). In rural areas, as demographics evolve, as small towns decline, and as other communities change in nature—often becoming “bedroom communities”—accessibility can be a very dynamic issue.

“Availability” refers to an adequate supply of providers such that appointments for services can be obtained in a reasonable time frame. A dentist might be accessible, but if appointments aren’t available for six months, care can hardly be said to be available. In many ways, availability is a function not only of the complex mix of providers (the dental teams and practices in an area), but also the demand for services that is expressed by the population. The availability of a professional workforce that is dispersed appropriately is becoming increasingly problematic, particularly for rural areas.

“Acceptability” of care implies that health care providers are available who demonstrate culturally sensitive, respectful behaviors and values. Increasingly, providers who speak the language of the patient are seen as critical.

Keeping these access issues in mind, we can note that as elsewhere in society, the poor and disadvantaged have more oral health problems and face greater problems obtaining care than do their more advantaged counterparts, whether in urban or rural areas.

That said, the oral health of the rural poor tends to be compromised by poor dietary habits and inadequate nutritional resources, a lack of financial resources to purchase care, lack of access to providers, lack of water fluoridation, and a host of other factors, often including insufficient knowledge about the importance and value of oral health. In rural areas, ethnic minorities and the poor are at greatest risk for dental health problems and lack of access to employer-based insurance plans. Farmers and other self-employed workers are similarly disadvantaged with respect to dental insurance programs. Rural residents in general most commonly face problems of access to care, inadequate insurance and financing mechanisms, and lack of community water fluoridation.

While rural residents have particular cause for concern, the reader must exercise caution: generalizations, many of which cannot be substantiated, abound in reference to rural America. The Pine Ridge Reservation in South Dakota, the Appalachian foothills of southeastern Ohio, and the Berkshires in Massachusetts, by way of illustration, are all rural, but have different populations, different social and economic systems, and thus very different medical and dental care “delivery system” problems.

Thus, while acknowledging the vast differences in rural America, we can note that demographic trends and other health system factors tend to exacerbate oral health disparities and dental services for many persons living outside urban areas. Rural areas tend to have older populations, and those citizens are less likely to be covered by dental insurance. Dental care is likely to be less accessible and, in some instances, to be less comprehensive. Although it is not commonplace, some rural (and, indeed, some urban) dentists find it difficult to keep current on new developments in dental materials and techniques, thereby denying their patients potential benefits from new developments. Rural citizens are less likely to have access to fluoridated water supplies and, in areas of extreme poverty, may have substandard diets. When faced with dental emergencies (e.g., severe injuries to the mouth), rural residents often drive farther to reach a dental office or medical center. Physicians and emergency medicine specialists generally are ill-equipped to treat dental trauma. Oral surgeons may be several hours distant.

Rural dentists face problems of their own. They tend to be older than those in urban areas, have smaller practices, have greater difficulty recruiting highly skilled assistants and hygienists, and, increasingly, have difficulty competing with or participating in managed care systems.

Access to dental specialists for referral and consultation is a problem in many rural areas. While the majority of the nation’s dentists are general practitioners and are technically skilled in all aspects of dental care, many prefer to refer more complex cases to specialists. Nonetheless, when faced with having a patient travel 100 miles or more to an endodontist for a root canal or treating it themselves, they may treat the case rather than subject patients to long, painful delays in treatment.

Another drawback to rural practice can be the lack of adequate backup for weekends and vacations. Dentists in remote rural areas may also find it difficult to participate in continuing dental education. Continuing education, often located in dental school facilities, is usually offered in urban areas. This involves greater costs and necessitates longer periods of absence from the practice when compared to the urban practitioner. Rural study clubs help dentists stay current, but often do not provide the quality of programming frequently required by state agencies or associations for licensure or membership.

Although rural residents face many problems regarding dental health, they are not completely disadvantaged when compared to their urban counterparts. Rural patients may find it easier to establish closer, long-term relationships with dental providers, and emergency care (e.g., attention to a toothache in the middle of the night) is often more readily available in many small towns than in large metropolitan cities.

Another advantage is that many young dentists and their families are drawn to rural communities because they offer more attractive lifestyles than highly urbanized cities. Outdoor recreational activities, slowerpaced living, lower crime rates, a stronger sense of community, and community-based schools frequently are cited as advantages of smaller communities by dentists looking for new locations. Dentists drawn to rural communities for such reasons often become involved in community affairs and are more likely to be active participants in local and regional health planning activities.

Despite these advantages, however, actively recruiting dentists to rural communities is a critical piece in the access puzzle. Both the community and local professionals must work together to recruit dentists, usually as young associates or as eventual replacements for retiring dentists. Doing so is sometimes difficult and may require several years of planning. Nonetheless, bridging practitioners in this manner is much easier and far more effective than recruiting dentists to practices that have been dormant for a year or more following the death or retirement of a dentist. Few young dentists are willing to risk establishing a solo practice in areas where residents have grown accustomed to seeking care elsewhere. The start-up costs to establish or retrofit such practices is high, usually running six figures, and young graduates, who often carry educational debts in excess of $100,000, may face difficulties in obtaining financing for such ventures.

Spousal employment is also an issue of concern to dentists as they make location decisions. More and more dentists are married to trained professionals, and rural communities that might represent exceptional practice opportunities for a dentist often are unable to provide appropriate employment opportunities for the spouse.

Looking to the future, one should note that much research in disease prevention and control is underway. Most exciting are new developments in genomics, which may someday enable dentists to help people regenerate lost bone and teeth, prevent specific diseases, and help us better understand genetic issues which contribute to developmental problems that have oral manifestations such as cleft lip and palate.

In addition, technological advances in computerized communication (e.g., interactive television, distance education and the Internet) may help overcome some problems associated with the relative isolation of rural practitioners. These technologies are being used currently to extend dental expertise to rural clinics and remote communities, and their use is expected to become widespread within the next decade.

Perhaps the most significant near-term developments will emerge in the arena of dental care financing. After years of debate over health care financing, both political parties seem to agree (in 2008) that health care reform has become a necessity. As noted earlier, the cost of dental (and medical) care is projected to escalate over the coming decade. Health care reform holds promise of improved service for all Americans. Improved payment mechanisms will be fundamental to an improved health care system, but for rural America, other measures will be needed to ensure access to care. Solutions may include new types of providers, innovative practice models, greater collaboration between medical and dental clinical providers, or other as-yet untried ideas. Absent innovative thinking, collaboration between the public and private sectors, and the political will to eliminate health disparities, the families of farmers, self-employed workers, and small business owners, the elderly, and the rural poor (many of whom are ethnic minorities) will be left behind as the U.S. moves forward.

— David O. Born

See also

• Health and Disease Epidemiology; Rural Health Care; Nursing and Allied Health Professions; Nutrition; Policy, Health Care

References

• Burt, Brian A. and Stephen A. Eklund, eds. Dentistry, Dental Practice and the Community, 5th edition. Philadelphia, PA: W.B. Saunders Company, 1999.
• Dental, Oral and Craniofacial Data Resource Center. Oral Health U.S., 2002. Bethesda, MD: Dental, Oral and Craniofacial Data Resource Center, 2002.
• Eberhardt, M.S., Ingram, D.D., and Makuc, D.M., et al. Urban and Rural Health Chartbook. “Health, United States, 2001.” Hyattsville, MD: National Center for Health Statistics, 2001.
• Gamm, Larry D., Hutchison, Linnae, Dabney, Betty J., and Dorsey, Alicia M., eds. Rural Health People 2010: A Companion Document to Healthy People 2010. Volumes 1-3. College Station, TX: Texas A&M University System Health Science Center, School of Public Health, Southwest Rural Health Research Center, 2003-5.
• Gordon, D. “Where Have All the Dentists Gone?” Rural Health Brief. National Conference of State Legislatures, 2004.
• Hartley, D. “Rural Health Disparities, Population Health, and Rural Culture.” American Journal of Public Health (2004): 1,675-1,678.
• National Advisory Committee on Rural Health and Human Services. The 2004 Report to the Secretary: Rural Health and Human Service Issues. Report to the U.S. Secretary of Health and Human Services, April 2004.
• Ricketts, T.C. Rural Health in the United States. New York, NY: Oxford University Press, 1999.
• U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health, 2nd edition. Washington, DC: US Government Printing Office, November 2000.
• U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.