Recorded Aug. 1, 2017; broadcast on Aug. 28, 2017.
Health reporter Rebecca Smith recently sat down with Dr. John Dane, the current state Dental Director, and Gary Harbison, the Executive Director for the Missouri Coalition for Oral Health.
In this 30 minute Missouri Health Talks Special, they cover the Missouri Oral Health Plan, which runs from 2015 to 2020, advances that have been made in oral health policy and struggles Missourians still face when it comes to accessing quality, affordable dental care.
You will also hear conversations gathered by Smith in June at the 6th Annual MOMOM, or Missouri Mission of Mercy, in Joplin. This yearly, two-day dental clinic put on by the Missouri Dental Association provides free dental care for anyone willing to wait in line. This year approximately 1,200 people were served and more than $800,000 worth of care was provided.
Executive Director, Missouri Coalition for Oral Health
State Dental Director
Gary Harbison: We have made a lot of progress, and I think in terms of actually improving the oral health of the population, getting the adult dental benefit back into Missouri Medicaid, or MO HealthNet, is extremely important because that's actual access for care, and because of Dr. Dane's work, we know that a lot of people are getting care from that benefit that haven't had dental care in many many years.
But we know that we still have many many challenges. We know that overall, it's fair to say that the oral health of Missouri is poor. We have a lot of areas where access to oral health care is still a tremendous challenge - affordability is a big part of that. In many rural communities in the state, people simply do not have a local provider.
Dr. John Dane: If you were to say, "Who is having the worst time getting dental services?" If you're poorly educated, have [a] low income and you exist in a rural county, you have the most problem getting oral health care, and that has been true for a long time.
As of July 2017, we have 94 counties out of 115 that are designated dental professional health shortage areas. We actually have nine counties in the state of Missouri that there's not a dentist who's licensed in that county with an office address in that county.
Dr. Dane: When you start talking about systemic effects of dental disease, the medical community and healthcare in general relies on evidence-based types of dentistry and so there are not the double blind, randomized controlled studies that are done on populations at large to show that there is a direct link.
We're still at a situation where, for the most part, we don't have the proof that this one thing caused another with the possible exception of in pregnancy. There have been some well-controlled, randomized studies done on the effects of periodontal disease on preterm labor and low birth weight, and that has become a very well accepted in the OBGYN community - that mothers that have advanced periodontal disease are doing to be more prone to having premature births and smaller babies if they don't get to the dentist.
So part of your MO HealthNet benefits, even before we had adult dental services, was that if you were a pregnant mom, you got full dental services while you were pregnant and then six weeks postpartum.
Gary: The department of Health and Senior Services has done, and they are maintaining, a really great little study looking at expenditures for non-traumatic dental in emergency rooms, and the other component - where people end up in the hospital. I believe it is still around $17 million a year that is being expended on non-traumatic dental care services in emergency rooms.
By and large, that $17 million is not taking care of the underlying condition. It's assessment and some care that will reduce the pain and the infection that goes on. In the case where people have [gotten] bad enough to go into the hospital, of course that is an extremely expensive thing to do - for something that could have been dealt with by a dentist and never have gotten to that point.
Dr. Dane: Gary mentions the $17 million spent - that was in 2014. There were 54,000 ED visits in the state of Missouri that year for non-traumatic dental care. [Since] the advent of adult dental services, we have been tracking that, and while I don't have numbers for you, I can tell you that the trend line is down. We are having an impact. The Medicaid individuals that are being treated in the emergency room is decreasing.
Gary: From a policy perspective, that's been very important that Health and Senior Services has been able to put that data out because every legislator we talked with about ER usage for non-traumatic dental immediately saw that that was a red flag for a healthcare system that was not operating efficiently.
Dr. Dane: Cancer of the lip is usually quite treatable and the survival rates are very high in that area.
The issue with the silver fillings: We know that the times that silver fillings emit the most mercury is when they are first placed and, unfortunately, when they are taken out. The ADA's policy, as well as public health dentistry's policy, is that if you have a solid, well-placed silver filling that there are no caries [cavities] around, don't take it out, and anybody who goes around taking out sound restorations to replace them with something else, is doing you a disservice.
We have seen a spike now of cancers that are associated with HPV infection. You don't usually think of oral complications of HPV infection, but the good news is that those folks are relatively well-treated and survival rates are in the 70 to 80 percent [range] for those types of cancers that are linked to HPV infections.
You may hear from your dentist sometime in the near future, that they are recommending getting the HPV vaccinations for your kids because of that situation.
Gary: So, we are fortunate that we have two dental schools now. They both, to some degree, focus on trying to train people that are from Missouri communities and will go back to Missouri communities. Both dental schools have connections to Federally Qualified Health Clinics [FQHCs] that are more prevalent in rural areas on the practitioner side.
Obviously no school can force graduates of dental school to go into the underserved areas, and dental students come out with a lot of debt. They are very interested in paying that debt off, and we do support a loan repayment program because that gets people into these underserved areas. Again, we are butting up against limited funding available for that. We would like to see more money go into that, so we could see more folks go into these underserved areas.
Dr. Dane: We are working with some of our other funders in the state of Missouri that are trying to formulate a reasonable loan forgiveness or perhaps even scholarship situation for dentists that will commit to providing services in a particular area of need.
One of our biggest problems, of course, across the state of Missouri is that we have some of the poorest counties in the nation. In fact, I think if you looked at the top ten poorest counties in the nation, three of those are in Missouri.
So, if you are a dental student who's graduating from dental school with $250,000 worth of loan debt, and you want to go into private practice - you probably won't pick an office in Shannon County… It leaves these small communities and areas in the poorest counties of the state at a real disadvantage to attracting dentists to those areas.
Gary: From the Coalition's perspective, I would love to say that we would have accomplished everything that is in the plan. I would love to say that we had accomplished all the policy goals that the Coalition has put out. Realistically, we know for a lot of reasons we're not gonna quite be there. There will be plenty still to be done.
Dr. Dane: Specifically from the dental side of things, we'd like to see more children that are Medicaid eligible receiving care. We'd like to see an increase in the number of dental sealants that are placed for kids. We'd like to see oral cancer take a downturn in the state of Missouri. Physicians and dentists are working together to reduce the effects of periodontal disease, and dental caries [cavities] on overall health outcomes. And these are all goals that are attainable.
Gary: The thing that I would add is the idea that, as a culture, we will realize, policy maker and public, that oral health is essential to our overall health, and we all make it a priority. We make sure that we get it, so we don't have like we have now - large segments of the population who really think of it as something they don't really even have to worry about.
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