New oral health coalition expected to spur changes in state

By Tara Kaprowy
Kentucky Health News

For the past 30 years, Dr. Fred Howard of Harlan has been seating patients in his blue dental chair and telling them to open up. When they do, he's seen all kinds of scenarios, from toddlers whose teeth are already rotten from sucking on bottle filled with soft drinks to 20-year-old adults with no teeth at all. On some occasions, children walk in with such a severe abscess in their mouth their eyes are swollen shut.

Though the view can be grim, Howard said he has seen some improvements in his decades of practice, but with new changes in Medicaid managed care, the overwhelming prevalence of children and teens drinking soda pop and an embedded cultural belief in some areas that "teeth are just something to get rid of," Howard concedes that making headway can feel like one step forward and two steps back.

Enter the newly re-established Kentucky Oral Health Coalition, a statewide force whose goal is to ensure Kentuckians have happy, healthy smiles.

Dozens of organizers and stakeholders met in March to discuss the coalition's aims, and a membership drive is underway to build financial momentum. The coalition will promote oral health education, statewide partnerships statewide and advocate oral-health legislation. "I think they will turn into the advocacy group for dental change," said Dr. Julie McKee, dental director for the state Department of Public Health. "They're working hard to come up with a plan. They've got their heads on straight."

One of the major issues facing the dental profession is possible expansion of the scope of practice for mid-level providers, such as dental therapists who can assess, clean teeth, replace sealants, provide fluoride as well as fill cavities and extract teeth. As nurse practitioners do in the medical field, having such providers could help address shortages in rural areas, said Dr. Jim Cecil, former state dental director and coalition steering committee chair. The concept is in practice in 54 other countries, but the only U.S. states with it are Minnesota and Alaska, mainly because of opposition form dentists.

Andrea Plummer, coalition member and senior policy analyst for Kentucky Youth Advocates, acknowledged that scope-of-practice issues "can be a very tense subject" and "there would have to be buy-in" from members of the committee, who include dentists, but discussion is ongoing. Cecil said the issue is "something we'll need to look at and take a stand on eventually."

Howard (pictured with Gov. Steve Beshear at signing of the bill that requires dental exams for students starting school) favors the expansion, but doesn't feel Kentucky's oral-health problems can be solved just by putting more boots on the ground.

"The bottom line is: We can have twice as many dentists, have more dental hygienists, but if we don't change the mindset, if we don't provide the education, I don't think we're going to solve the problem," he said.

To that end, the coalition is also investigating ways to expand school-based health and dental education, either by finding funding, collaborating with groups that are already in place or advocating legislation changes, Plummer said.

A recently enacted state law requires children to get a dental screening before entering kindergarten, but there is little else in the way of legislation that requires schools to offer services to help students with dental problems, Plummer said. "Kentucky law says that students' health does affect their learning and schools should take steps to affect their learning but it's fairly broad," she said.

An analysis by KYA last year showed school districts spend less than 1 percent of their budgets on school health services.

Examining how to get more dentists to accept Medicaid patients is another hot-button issue. Of about 2,200 dentists statewide, only about 600 are enrolled in Medicaid, Cecil said, and "They feel like they're working for free" because of the program's low reimbursements. "In many cases, they're really not meeting overhead."

The administrative burden that comes with these patients has also gotten worse since Medicaid transitioned to managed care, Cecil said. "Everything they do has to be pre-authorized," he said. "That delays approval, delays treatment, delays payment."

Under managed care, Howard said, patients now need to come in twice to get a full complement of X-rays and radiographs done, which can not only make it hard on dental practices, but for patients as well. "The more times they have to come, that gives them more opportunities to miss appointments," Howard said.

The Oral Health Coalition also sees a need for "quality, updated data," Plummer said. Getting data was one of the successes of the first coalition, formed in 1990. Run by volunteers and funded by the dental schools at the University of Kentucky and University of Louisville, it was formed after the General Assembly told the schools that they either needed to work together or one could "risk being shut down," Plummer said. The group had several successes, including working with the state to conduct an oral health survey, lobbying legislators for oral-health measures and holding an annual symposium. But after more than 15 years, "It kind of just fizzled out a little bit," Plummer said. The group went inactive in 2006 but had some assets that the new group will take over.

The group's rebirth began in 2009, when Kentucky Youth Advocates was approached by the DentaQuest Foundation, which is connected to DentaQuest, one of the largest managed-care organizations in the country that administers dental benefits. DentaQuest officials were interested in seeing the coalition resurrected and offered $80,000 to KYA so it could provide the manpower to run it, Plummer said. It was the first time the coalition had funding to back it up. The KYA talked to state stakeholders and discovered "there really did seem to be an interest in putting a coalition back together," Plummer said. Planning began in earnest and in January the steering committee drafted by-laws. In March, 70 people showed up to the first meeting.

That gathering was not just made up of dentists, oral-health advocates and experts, Howard said. Members of the media were present, along with parents, health department officials, school nurses, students and educators. That made all the difference to Howard, who said he is inspired by what changes might occur and what education can take place. "When we have people from all these different venues, we have more of an opportunity to make a difference," he said.

The coalition's next meeting will be July 25. Those interested in attending or becoming members of the coalition can contact Andrea Plummer at aplummer@kyyouth.org or 502-895-8167. Dues for individual members are $25. Government organizations pay $100, nonprofit organizations pay $250 and for-profit organizations pay $500.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Diabetes can cause gum disease and tooth decay

Though it's commonly known that diabetes can affect organ function and eyesight, an oral-health expert points out that the disease can also cause tooth decay and gum disease.

"Diabetics with uncontrolled glucose levels tend to develop more gum disease and may lose more teeth than diabetics who have good control of their glucose levels," writes Dr. John Novak, associate director of University of Kentucky's Center for Oral Health Research, in an op-ed piece for the Lexington Herald-Leader. A high carbohydrate/sugar diet can also lead to high levels of sugar in the blood, which can hamper the way the body deals with infection, he writes. Gum disease may be the result because the gums are inflamed by the increased levels of bacteria living in the mouth.

Diabetes can also cause dry mouth, which "creates the perfect environment for the growth of bacterial plaque and for fungal infections such as thrush," he writes. To avoid these problems, Novak recommends brushing teeth and gums twice a day with a fluoride toothpaste, flossing every day and using fluoride mouth wash before going to bed.

Signs of tooth decay or gum disease include tender gums that bleed easily when brushing or flossing; teeth sensitive to hot or cold temperatures; loose or broken teeth; sores, ulcers or a burning sensation in the mouth; and bad breath or a bad taste. (Read more)

Like nurse practitioners in medical field, dental profession needs mid-level providers, expert argues

With 50 million Americans living in poor or rural areas where there are no dentists to go to — and that number expected to rise by more than 5 million if the Affordable Care Act stands — states and the federal government should be training dental therapists to help solve the problem, argues Louis W. Sullivan, a physician and former secretary of the Department of Health and Human Services, in an op-ed piece in The New York Times.

"We have two years to prepare before millions of children will be entitled to access to dental care," he writes of the impending eligibility expansion under the ACA. "Access means more than having an insurance card; it means having professionals available to provide care. Public officials should foster the creation of these mid-level providers — and dentists should embrace the opportunity to broaden the profession so they can expand services to those in need."

Dental therapists provide preventive care and "routine procedures like sealants, fillings and simple extractions outside the confines of a traditional dentist's office," Sullivan writes. While they are "common worldwide," only Alaska and Minnesota allows them to practice. Legislation is pending in five other states. Generally, dentists have been opposed to such changes.

Sullivan points to Alaska as a model example for how these therapists can fill gaps in places like remote villages "only accessible by plane, snowmobile or dogsled, where high school seniors once graduated with full sets of dentures." In 2003, the state sent students to New Zealand to be trained as therapists. Now, therapists serve 35,000 Alaskans. They "travel to small clinics and schools, often carrying their equipment with them. They consult with a supervising dentist from the region but do most procedures themselves. Many were raised in the communities in which they now work, so they understand the culture," Sullivan writes.

Sullivan points out dental disease is the No. 1 chronic childhood disease in the country, responsible for more children needing treatment than asthma. In 2009, more than 830,000 visits to the emergency room were due to preventable dental problems across the nation, he points out. But dentists are in short supply and will be even harder to see if the ACA is upheld by the U.S. Supreme Court. "In a nation obsessed with high-tech medicine, people are not getting preventive care for something as simple as tooth decay," he writes. (Read more)

State starting free training for dentists in pediatric dentistry

One of the many problems with Kentucky's oral health is that not enough dentists are willing to accept children as patients, or lack proficiency in treating children when they are around age 1, the recommended time for a child's first dental visit.

Next week, the state Department of Public Health will start to offer free continuing education for dentists and other oral-health professionals who need or want training in pediatric dentistry, funded by a federal grant.

The Access for Babies and Children to Dentistry (ABCD) program will have one-day training sessions in Lexington on Friday, April 6, at the Embassy Suites on Newtown Pike next to the interstate, and in Somerset on Wednesday, April 11, at the Hampton Inn on US 27. Both sessions will start at 8:30 a.m. The sessions offer 8 continuing education units out of a possible 20 in the program.

For more information about the training, and to register for it, contact Meghan Towle at Meghan.Towle@ky.gov or 502-564-2154.

Board of Dentistry's relaxation of limits on hygienists is the latest sign of hope in Kentucky's all-too-grim story of oral health

By Al Smith
Kentucky Health News

With nearly a fourth of Kentucky’s 1 million children living in poverty and suffering some of the worst oral health in America, the state Board of Dentistry voted Saturday to develop regulations to permit hygienists to treat children in a public health setting perhaps stemming a near epidemic of tooth decay in the very young.

Hygienists will still be responsible to dentists when working in public-health settings such as schools, where they can apply preventive treatments on their own if the new regulation wins legislative committee approval. It isn’t as far as we want to go in confronting our horrific problems, but it may remove stones in our path that have kept a tight control on the use of hygienists.

In the past, organized dentistry in Kentucky, fearing competition from hygienists, has opposed expanding their scope of practice, but as Kentucky remains stalled near the bottom of state rankings of oral health, younger dentists are accepting the need for change, says Dr. James Cecil, a retired dentistry professor at the University of Kentucky.

Saturday’s action by the Board of Dentistry partly may have been “from desperation, over recent bad publicity as the popular press portrays the profession as unresponsive to the needs of our poor citizens,” Cecil said in an interview. “While dentistry still remains where medicine was 20 years ago,” when many doctors opposed licensing physician assistants and nurse practitioners, Cecil said dentists “will learn they can make more money when their services become more available through greater use of auxiliaries such as the hygienists.”

Cecil, former chief dental officer for the U.S. Navy and distinguished as a national leader in public health, earlier last week participated with Kentucky Youth Advocates in the organization of a new Kentucky Oral Health Coalition, whose startup is funded by a foundation grant to KYA.

This coalition of various organizations, including public health departments, nurses, physicians, insurers, and some dentists, will be independent of dental associations or the state’s two dental colleges, and it will campaign for better programs for general as well as oral health.

In the early months of a year when the Kentucky General Assembly, like the U.S. Congress, has reached little agreement on public issues, the state Department of Public Health, actively supported by Gov. Steve Beshear, seems to be gaining traction on oral-health needs.

Grants from the Appalachian Regional Commission are expected to go to two of 13 new local health coalitions in Eastern Kentucky. The grants will pay for one mobile dental van and equipment to reach out to an area with children whose teeth are so decayed they were one focus of an ABC "20/20" documentary viewed by 11 million people in 2009.

Through funding by the federal government, the oral health program will begin training general dentists in more pediatric care. And with additional funding from ARC, this project focuses on dentists in the ARC counties for participation.

Meanwhile, Dr. Cecil and KYA hope to organize more local dental coalitions in rural Western Kentucky. Coalitions may decide to include ‘senior days’ to help older citizens with appalling dental health needs.

There are now 25 such coalitions in the state. As more are established, the challenge is to expand the reach of the state’s 3,000 hygienists, to assist and encourage the state’s 2,400 active dentists to become more pro-active about solving problems that drag down oral health in Kentucky, and to educate parents to care for their children’s teeth, beginning in their first year of life.

Historically, in a culture with so much poverty, Kentuckians have stoically accepted being toothless in old age as part of the price. First, though, there are awful workforce problems. What starts with neglect in childhood evolves into a workforce of adults with severe tooth loss and poor self-image, plus illnesses associated with dental disease (obesity, diabetes, strokes, heart disease and Alzheimer’s) and last, a distressing cohort of toothless elderly poor, sadly, among the highest in the country.

It's a grim story, but Cecil sees determination in the profession to address the problems. With a new added role for hygienists, he says, “The dam may be broken.”

Journalist Al Smith, Lexington, a former federal cochairman of the ARC, and co-founder of the Institute for Rural Journalism and Community Issues at UK, is the retired host of KET’s "Comment on Kentucky."

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

More young kids going under anesthesia to fix bad dental problems

Preschoolers are increasingly having to undergo extensive surgery to get fix the cavities they've gotten from lack of brushing, get root canals or have teeth extracted.

Five years ago, the Centers for Disease Control and Prevention found the number of preschoolers with cavities had increased — the first time that had happened in 40 years. "Dentists nationwide say they are seeing more preschoolers at all income levels with 6 to 10 cavities or more," reports Catherine Saint Louis for The New York Times. "The level of decay, they added, is so severe that they often recommend using general anesthesia because young children are unlikely to sit through such extensive procedures while they are awake." (Times photo by Stuart Isett)

"We have had a huge increase in kids going to the operating room," said Dr. Jonathan Shenkin, a pediatric dentist in Augusta, Me., and a spokesman for the American Dental Association. "We're treating more kids more aggressively earlier."

Causes for the increase can be linked to lots of snacking and juice or other sugary drinks before bedtime; kids drinking bottled water rather than tap water; a lack of knowledge that infants should go to the dentist by age 1 to be assessed for cavity risk.

Parents can sometimes confused dental decay with teething and don't realize there is a problem until teeth break or the pain becomes so bad the child cannot sleep. (Read more)

As with health care reform, dentistry should move from volume to value, report urges

Dentists should be paid according to the outcomes of their patients and should be monitored more closely given that there is great variability and expense when it comes to dental care, a new report argues.

"I think there is broad consensus that the current oral health system doesn't meet the needs of a significant portion of the population," said Paul Glassman, professor of dental practice at University of the Pacific Arthur A. Dugoni School of Dentistry and lead author of the report "Oral Health Quality Improvement in the Era of Accountability."

The report, funded by the W.K. Kellogg Foundation and the DentaQuest Institute, was released as the U.S. healthcare system is undergoing a transition from the "pay-for-performance" model to "value-based care." The paper argues oral health should likewise move in the same direction and make the transition from "volume to value."

The report found dentistry is the second-highest out-of-pocket health care cost after prescription medicines, and, like health care in general, its cost is increasing, reports Laird Harrison for Medscape News. Another issue is the government just pays for about 6 percent of dental care nationally, the report found, leaving people to pay for care themselves.

While expensive, the care dentists give can be inconsistent, the report found. Though Glassman said dentistry is not lacking in standards, there is limited evidence of the best practice for most dental procedures, the report found.

Another issue, the report contends, is dentists are paid according to what they produce, not by how successful they are in their outcomes. As such, dentists are resistant to change since there are few incentives to implement quality improvement programs. "If the question is 'what's the optimum system for providers,' then many feel the optimum system is what we have now," Glassman said. "If the question is 'what's the optimum system for the public,' then you will come to a different set of assumptions."

To help improve the system, the report recommends a number of proposals, including:

• The increased use of electronic health records

• Development and use of measures for oral health outcomes

• Tying incentives to the oral health of the population being served

• Relying more on allied dental professionals and non-dental professionals

It also suggests relying more heavily on telemedicine, with Glassman envisioning "hygienists and dental assistants going into schools, nursing homes, and other areas with underserved populations to deliver preventive care," Harrison reports. "Dentists, monitoring from afar with access to dental charts stored on the Internet, could gain more patients."

Steven Silverstein, director of the graduate program in dental public health at the University of California San Francisco, said the report was "outstanding" and agreed that the care dentists give can be inconsistent, saying, "If you ask 10 dentists to look at a patient you will get 10 different opinions." Part of the problem, he said, is 98 percent of dentists either practice alone or with one or two partners.

Silverstein did take issue with the fact that the report did not mention the high cost of dental education; didn't take cosmetic dentistry into account; and it did not explain how reform could lower the cost of dental care. (Read more)