The Issue That Won’t Go Away
New chair of public health dentistry confronts the challenges of access to care
Among the statistics brandished by dental educator Caswell Evans during his talk at Tufts School of Dental Medicine was this: approximately 80 percent of all dental disease in the U.S. occurs in 20 percent of the population. As a young dentist working in remote communities and on Indian reservations in the 1980s, Mark Nehring witnessed the human stories behind those numbers.
“I saw more disease than you could ever imagine,” he says of his time working with the U.S. Public Health Service’s National Health Service Corps and Indian Health Service in Illinois, Montana and North Dakota. In remote regions of these states, generally beset by poverty, he saw patients whose oral health had often been neglected for years, “I did procedures and treatments for chronic conditions that I would never have seen in a suburban practice,” he says. “And I began to question the existing attempts to contain oral disease. I developed more and more interest in approaches to preventing the disease that I was seeing in such large amounts.”
So he made the jump from rural clinician to public health administrator, serving with the federal government during the 1990s and 2000s, when the dental profession slowly became aware of what is now called oral health-care disparities. In his new role at Tufts, as the Delta Dental of Massachusetts Professor in Public Health and Community Service and chair of public health and community service, Nehring wants to marshal the ideas of students and faculty to address access to care, now the most daunting challenge in dentistry.
“All of us in the profession—academia, the private sector, the public sector, policymakers—we’re all part of the solution,” he says.
From 1988 until his arrival at Tufts in February, Nehring worked for the Public Health Service and the Health Resources and Services Administration (HRSA) in Rockville, Md., most recently as the acting chief dental officer for HRSA and chief dental officer for HRSA’s Maternal and Child Health Bureau. During that time, he says, public health dentistry was forced to shift its emphasis and approach.
“In the past 30 to 40 years, public health dentists were trying to focus on prevention,” he says. However, the existing structure within dentistry compensated private practitioners primarily for treatment. “My take was that public health dentists were kind of challenging the rest of the profession to do it their way by applying guilt, appealing to social responsibility. But those kinds of pleas from the public health side didn’t necessarily fit the private-practice models,” he said.
Now public health specialists have begun to focus on ways that access to care can be expanded and integrated into the private-practice model, Nehring says. “The private practice is the 900-pound gorilla, and you cannot make a difference without that participation,” he says.
Change will come, Nehring says, only if the profession can take full advantage of the existing workforce. That includes looking at “adequate or fair reimbursement” by public insurance programs such as Medicaid for private practitioners, he notes. Other approaches include educating physicians—especially those who treat pregnant women and children—about the relationship between oral health and overall health; expanding oral health services to schools and community health clinics and continuing to assess the role of nontraditional providers, such as dental therapists and hygienists, in treating underserved patients. “There’s no silver bullet to solve the access issues,” he says.