Call to Action
Dentistry must rise to the challenge of providing care for all
“The profession and organized dentistry have been tepid, non-responsive and/or hostile to the challenges of access to care and health disparities, with a few exceptions. The status of the profession and the ongoing relevance of the profession are in jeopardy.”
With those strong words—albeit delivered in a gentle manner—Caswell Evans, a distinguished voice in public health dentistry, issued a clarion call to Tufts Dental School faculty and administrators, alumni, donors and others in May in a lecture titled “Access to Care, Health Disparities and Social Justice: Is the Profession Up to the Challenge?” The lecture marked the appointment of Mark Nehring as the Delta Dental of Massachusetts Professor in Public Health and Community Service and chair of the department of public health and community service.
Evans, the associate dean of prevention and public health sciences at the University of Illinois, Chicago College of Dentistry, was the executive editor and project director of the 2002 U.S. Surgeon General’s report on oral health in America and a member of the Institute of Medicine’s Committee on Improving Access to Oral Health Care for Vulnerable and Underserved Populations.
Organized dentistry, Evans said, has failed mightily in responding to the growing crisis of health disparities and access to care. Far too few dentists treat Medicaid patients, and the profession has a record of fighting against policies that could increase access to care for the poor, the elderly, those living in rural communities or other underserved groups.
“The oral health-care system in America is currently designed around the needs of the dentist, not the needs of those who are underserved,” he said. While the profession still has an opportunity to step forward, he said, “the window is closing.”
The problem, Evans continued, has evolved from the traditional training and outlook of dental schools: Dentists historically were not educated to see themselves as an integral part of the broader health profession. And then there is the “tug and pull” of dentistry as a business, alongside its professional mission. “That is a scenario we have not fully come to terms with,” he said.
The access issue has been percolating for decades. The stage was set when the dental establishment fought to have dental care excluded from the Medicaid and Medicare programs when they were created in the 1960s—successfully, in the case of Medicare. But it came to wider attention with the release in 2000 of the surgeon general’s first-ever report on oral health, which stated: “There are profound and consequential oral heath disparities in the American population.”
“That began to really get that ball rolling,” Evans said. In 2003, the surgeon general’s office issued its National Call to Action to Promote Oral Health. Then in 2007, a 12-year-old Maryland boy, Deamonte Driver, died of an infection triggered by an untreated dental abscess. A lack of dentists willing to accept Medicaid patients, along with glitches in Medicaid paperwork, meant he did not receive care until the infection had spread to his brain. His death, reported in The Washington Post, put a human face on the problem for Congress.
Concurrently, the issue of mid-level providers—dental therapists who can do procedures such as cleanings, restorations or uncomplicated extractions under the supervision of a D.M.D. or D.D.S.—surfaced. Such a model has existed since 2005 on tribal lands in Alaska, despite an unsuccessful legal challenge by the American Dental Association and the Alaska Dental Society. “Part of the argument in that suit,” Evans said, “was that no care is better than some care. And so here I ask: is that our message?”
One positive recent step, he said, was the formation in 2009 of the U.S. National Oral Health Alliance, a collaboration of dentists, educators, insurers, the dental products industry, physicians and policymakers. The group focuses on prevention and public-health infrastructure, oral health literacy, collaboration between dentists and physicians in providing care, financing models and strengthening the oral health delivery system.
In response to an audience question, Evans acknowledged that for recent graduates entering dental practice, the need to repay student loans plays a key role in career decisions. “The increasing indebtedness of students is a huge problem, and it certainly limits options,” he said. “What I share with students is that we’re not necessarily expecting any student to singled-handedly take on this problem, or even go into a public health position. Even if they are in private practice, that is public service, in the sense that they should be available to all of the public. Everyone has an opportunity to find something they can do to ameliorate the problem, and they should look for those opportunities.”