Poor oral health costs communities in many ways

Sept. 21--Poor oral health, like other chronic health conditions, is a problem for the River Region, experts agree, and the need for attention is great. But the root causes of that poor oral health are debatable, as are the potential solutions.

The financial and social causes were addressed by a number of experts at a recent Oral Health Conference 2014, sponsored by Envision 2020 and held at Auburn Montgomery. Envision 2020 is a strategic planning group that works to find solutions for social issues in the five-county River Region.

Oral health, or the lack of it, is a community issue, said Earl Fox, M.D., the keynote speaker at the conference. Children with poor oral health are three times more likely to miss school, and in adults, problems in the mouth exacerbate other health issues such as diabetes, in addition to causing lost productivity at work, Fox said.

"It's the entire body we're talking about, not just the mouth," said Fox, who is professor emeritus at the Miller School of Medicine at the University of Miami and founding director of the Florida Public Health Institute. He's also worked for public health agencies at the federal and state levels and might be remembered by some Alabamians as the state health officer in Alabama from 1986 to 1992.

Fox offered troubling statistics on Alabama's children: More than half of the kids in third grade have had some dental decay, and one in five kids in third grade have untreated dental decay.

Getting in front of the problem is key. "Prevention is the word," Fox said, and it shouldn't fall to just the dentists and dental hygienists. Other health care professionals, including nurses, physicians assistants and pediatricians, can be part of prevention interventions; so too can daycare workers, teachers and Head Start personnel, Fox said.

He suggested putting dental hygienists in medical offices to screen for early signs of tooth decay, apply varnishes and do education.

No one on the panel of experts at the Sept. 12 conference took issue with Fox's call for prevention. Most agreed that at the root of prevention is education -- educating parents on the need to get kids in for regular checkups and making sure adults understand the need for their own dental health.

"What it boils down to is really educating the patients on their dental health being an investment, not an expense," said Christina Cox, DDS, a practicing dentist and president of the Second District Alabama Dental Association. "Really investing on explaining to them why they should keep their teeth, why we should not be pulling their teeth, why they should be making it a habit to come in for their six-month checkups."

Fox said that especially in the Southeast, there's a "big" problem with dental access. Citing a Pew Charitable Trusts analysis of 2013 data, Fox said Alabama ranks third among states with the worst dentist shortages. The state is behind only Mississippi and Louisiana, with an estimated 24.4 percent of the state's population living in a dentist shortage area.

And Fox noted that the situation will likely worsen, with the aging workforce of physicians and dentists. The average age of physicians in Alabama is 53, and he suspects it's about the same for dentists.

Michele M. Waren, associate executive director for the Alabama Dental Association, countered by saying that for children, it isn't access as much as it is utilization. "When children do have access available, many of them do not access that care," she said.

In a discussion of funding, Roosevelt Daniel, DDS, who practices in Montgomery, said the business model of not just dentistry, but medicine in general is going to have to change.

"There's just no way that people can get adequate medical care with the system we have now," Daniel said. "I spend a lot of time chasing insurance companies myself. Reimbursements are going down.

"It can't be a system where, the more sick people I see, or the more cavities I fill, the more money I make," he said. "It's going to have to be a preventive system."

Fox cited data from the Pew Center for the States that in 2011, 52 percent of U.S. children enrolled in Medicaid did not receive dental care. In Alabama that same year, 45.9 percent of children enrolled in Medicaid did not receive dental care.

"I can tell you, in most states, a very small percentage of dentists take Medicaid patients," Fox said.

But Waren, the Alabama Dental Association executive, countered that it's still a utilization issue. "In 2013, there were Medicaid-providing dental offices in the River Region with empty chairs, with no patients to treat, and they were there, ready to treat them," she said.

The discussion came back to education. State Sen. Paul Bussman, who is also a dentist, said the community will have to help bring people in for dental care. "We can figure out a way to get access to care. I can't figure out a way to get 50 percent of the insurance patients to come to the office. I can't figure out how to get 80 percent of the people who have Medicaid coverage to come to the office."

When the panel opened to comments from the floor, the first was from a familiar name in Alabama public health. Mary McIntyre, M.D., is the assistant state health officer for disease control and prevention and acting state epidemiologist for the Alabama Department of Public Health.

McIntyre said that "in a prior life" she worked at Medicaid for 10 years and had the opportunity to testify before Congress about oral health and the successes seen in Alabama.

The state went from a 21 percent utilization rate with children to over 50 percent, McIntyre said, "which is not where we want to be, but it's a whole lot better than 21 percent, which is what it was in 1997."

She said that the key is to focus on the overall person and prevention. The state addressed women who were pregnant and put programs with curriculum in place that are no longer being used in daycare centers. The former 1st Look Program was designed to reduce early childhood cavities and tooth decay by encouraging primary care physicians to perform dental risk assessments and provide anticipatory guidance.

McIntyre said that program and all its training, for which there are CMEs, is still online and available.

"So I'm just asking you to remember that there is information available, resources that you can dust off. ... Educate them where they are."

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