Putting Teeth in Health-Care Reform
Advocates Press to Have Dental Issues Addressed: 'We're Always Left Out'

By Mary Otto
Special to The Washington Post
Tuesday, June 23, 2009

The 2007 death of a Prince George's County boy because of an untreated dental abscess was a tragic reminder of the connection between oral health and overall health.

Yet dental care remains the most common unmet health-care need of children in the United States. Tooth decay is five times as likely to be found in children as is asthma, which, like most common illnesses, is covered by health insurance. But at least 26 million children lack dental coverage, more than twice as many as lack medical insurance, according to federal health statistics.

Among adults, oral cancer kills more Americans than cervical cancer, and research suggests that oral infections can affect pregnancy outcomes and complicate chronic diseases such as diabetes. Still, 82 million adults have no dental insurance.

As the Obama administration rolls out its massive health-care reform effort, many dental-health experts worry that a golden opportunity is being missed. "Is oral health care getting enough attention in the current health-care reform discussion? The fast answer is no, and the door is closing," said Yolanda Bonta, a New Jersey dentist who is active in the national Hispanic Dental Association.

"We're always left out a little," said Michael Battle, a Charlotte dentist and president of the National Dental Association, which represents 6,000 black dentists.

Oral-health professionals fear that dental issues have a tenuous place at best in the national debate. "If we could be at the table instead of on the menu it would be great," said Kathleen T. O'Loughlin, a Massachusetts dentist, educator and executive director of the American Dental Association, which has more than 157,000 members. Dental care, said O'Loughlin, "is an essential part of overall health, and it shouldn't be overlooked."

Burton Edelstein, a professor of dentistry and health policy management at Columbia University, says it has been "very challenging" to try to join the debate: "The mouth," he said, "is the only body part or essential organ that is excluded from policymakers' routine consideration of health and health care."

No Easy Task

Closing the gap between the worlds of dental care and medical care, with their separate histories and cultures, and their separate finance and delivery systems would be a formidable task. Edelstein, who is the founding chairman of the nonprofit Children's Dental Health Project, sees a glimmer of hope in the inclusion of several dental provisions in the 615-page first draft of the Senate Health, Education, Labor and Pension Committee's health-care reform bill.

The draft includes dental care in a list of benefits that children should receive and cites the importance of disease prevention and surveillance, safety net programs, and changes in the dental workforce and public-health infrastructure.

Advocates aren't focusing solely on the Senate bill, as there are other, competing bills still to come. Rep. Elijah Cummings (D-Md.), who has emerged as a leading congressional proponent of oral health, is working to keep the issue visible as the House of Representatives crafts its own version.

"It is important that the health reform plan includes full integration of oral health into our nation's health-care system," said Cummings. He called himself "cautiously optimistic" that such principles as incentives for dentists to treat more poor patients, oral-health literacy education for parents, preventive care programs for children and innovations to increase the dental workforce will be included in the House health-care reform bill.

The death of 12-year-old Deamonte Driver a few miles from the Capitol reminded lawmakers of the disparities that dental-care advocates had been warning about for years. One of these was David Satcher, who as U.S. surgeon general in 2000 called oral disease a "silent epidemic" afflicting millions of minority and low-income Americans.

A Lethal Infection

Deamonte, who had been living in a homeless shelter before moving into his grandparents' mobile home in Clinton, died from a dental infection that spread to his brain. A routine, $80 tooth extraction might have saved his life. As is the case with many poor families, transience as well as problems with transportation, phone service and mail delivery complicated the Drivers' search for care. The death spurred congressional hearings and gave lawmakers and the public new insights into failings within the Medicaid system charged with providing dental care to millions of poor children. The revelations led to reforms of the system in Maryland. Often invoking Deamonte's name, Cummings went on to help lead a successful fight for the inclusion of a dental entitlement for the children of the working poor under the reauthorization of the State Children's Health Insurance Program, or S-CHIP. The bill, vetoed twice by then-President George W. Bush, was signed into law this year by President Obama.

If there has been progress in getting dental care into the current debate, it has been built upon the events of the past two years, said Edelstein.

"The attention that oral health is getting is, I believe, a direct result of concerted, ongoing and persistent efforts by oral-health advocates and their technical advisers to keep the lessons learned by Deamonte Driver's death and in the [S-CHIP] reauthorization before policymakers during health-reform development," Edelstein said.

But the fact that dental care was not included as an entitlement for the first decade of the S-CHIP program is a reminder of the chasm between dental care and general health care.

Allen Finkelstein, chief dental officer for AmeriChoice, a UnitedHealth Group company, acknowledges that gap and said it must be closed to ensure better care.

"Care of the teeth needs to be integrated with care of the rest of the body," said Finkelstein, who advocates putting the delivery of both medical and dental services under a system of "health homes" and requiring children to visit a dentist annually before returning to school.

"Fundamentally, our health-care system and the laws and regulations that govern it must put dental prevention and care on par with the rest of our health," said Finkelstein.

And any reform must include a changed approach toward delivering dental care -- a move away from the old model of treating decay and disease and toward disease prevention and oral-health promotion, Finkelstein said.

For reform to be most effective, dentists and public-health experts must be active participants in the discussion, said Dushanka Kleinman, a dentist and associate dean for research and academic affairs at the University of Maryland School of Public Health.

"There is still time for this inclusion," Kleinman said, adding: "We must especially address the design of new programs to meet the needs of low-income and under-served populations."

The Americans who have the most at stake in dental health reform are the poor, agreed ADA president O'Loughlin. While most middle- and upper-class Americans have access to good dental care, national reform efforts should focus on bolstering the Medicaid and public-health systems, she said.

Ultimately, providing a system of preventive care to the poor could save money and head off more preventable deaths, she said. "If Deamonte Driver never had caries [dental cavities,] he never would have died," she says. "It was a preventable disease."

Support for reform came last week from the front lines of everyday oral-health care: dental hygienists. They foresee a bigger role for themselves in preventive care to the poor and under-served, said Karen Sealander, Washington counsel for the 150,000-member American Dental Hygienists' Association.

As she spoke last Wednesday, her army of lobbyists was converging on Capitol Hill. Hundreds of hygienists, nearly all women, armed with talking points and dazzling smiles, spent the day meeting with lawmakers and their staffs, asking about their own dental histories, discussing dental workforce development and emphasizing the urgency of preventive care.

They came from 39 states but they rallied under one slogan: "Put Teeth in Health Reform."

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