I was asked to share my thoughts and experiences as an
individual, private practice dentist, as well as a state
dental society leader, on how workforce issues affect
access to oral health care for the underserved. Whenever
this topic comes up, I ask, "Exactly what are we trying
accomplish?" For my part, our ultimate goal should be
achieving optimal oral health for everyone who seeks
I remain frustrated and saddened that so much time and
debate and so many resources surround one proposed solution
—the so-called midlevel provider—which focuses
exclusively on treating disease that has already occurred.
This is essentially increasing the speed at which you're
bailing a very leaky boat. It ignores the need for a
comprehensive strategy that diagnoses the full extent of
the driving factors. Access to clinical care is just one of
many factors needed to improve oral health. Workforce is
but a small part of the access factor.
The patient base in Greenville, South Carolina, runs the
full spectrum, as does the local economy. We have
international corporations but also abandoned textile mills
and their displaced workers. During my 27 years in general
practice here, I have treated patients that reflect this
cross section. For the most, part patients show similar
oral health requirements regardless of their economic
Some in the community seem to take the "I'm sick/walk
in" attitude toward health care. Many of those
advanced-oral-disease, non-patient-of-record individuals
just end up at the emergency room, where their treatment
costs much more than it would in a dental setting and does
nothing to cure the underlying disease. This is no pathway
to oral health.
Dr. Frank Bowen, director of the Volunteers in Medicine
clinic in South Carolina, says their mission is shifting
from acute care to wellness. Shifting to patient
empowerment, responsibility, and wellness must be one of
our goals. This is not a treatment-focused solution. We
have a Federally Qualified Health Center with a dental
clinic, as well as a very good free dental clinic. Yet we
still have a segment of the population not utilizing the
available care. How can adding more hole fillers convert
that into health? That requires navigators and social
workers, not adding treatment techs.
Dental disease is best managed by a patient-dentist
relationship that facilitates treatment and minimizes
recurrence of disease. This takes a long-term commitment
from both patient and dentist. Until there is a sense of
value for oral heath, with people both seeking professional
care and taking ownership of their own health, we will
never see the increase in utilization that should be a
natural driver for oral health.
As a profession, we still suffer from a Rodney
Dangerfield syndrome. Politicians, comedians, and other
public figures routinely joke that something awful is
"about as pleasant as a root canal!" Even in matters of
public health, dentistry often is not taken seriously.
Excessive soft drink consumption, combined with poor oral
hygiene, can devastate the teeth, a condition that some
dentists refer to as "Mountain Dew Mouth." Dentists in many
states have long lobbied to remove soft drink machines from
schools, but it was not until obesity became a major
concern that schools took action. We shouldn't quibble when
people finally get around to doing the right thing, no
matter what drives them to do it, but the societal failure
to value oral health is chronic and at times crippling.
Dentists are the doctors of oral health.
Dentists diagnose and cure disease. We eliminate pain and
infection. Our continually broadening scope of clinical
training, along with salivary diagnostics and improvements
in technologies such as imaging, is allowing dentists to
diagnose some systemic diseases early in their development,
with potentially life-saving outcomes. Most importantly,
with the possible exception of vaccinations, modern
dentistry evinces the most successful model of prevention
in all of health care.
Unfortunately, on the policy side, oral health remains
perennially short-changed, and the consequences of that
neglect on the most vulnerable Americans are accordingly
profound and tragic. I do not believe that surgical
intervention, especially given realistic expectations of
public oral health funding, will ever end the epidemic of
untreated oral disease. Prevention, with oral health
education as its foundation, can. You can't drill your way
to oral health.
Does the mom who gives her kids candy at the checkout
line know how to keep their teeth and gums healthy? Are
diabetics aware of the particular importance of monitoring
and maintaining their periodontal health? How many parents
know to get a baby to the dentist when her first tooth
erupts? The federal government spent millions educating the
nation about digital TV conversion. How much does it spend
on oral health education? The government offered coupons
for digital converter boxes for those who couldn't afford
one. Where are the dental care coupons?
This pervasive, societal failure to understand, value,
and act on the importance of oral health is a far more
meaningful factor than workforce. I base this on years of
experience as an advocate for better oral health in South
Carolina, a state with historically strong rates of dentist
participation in Medicaid.
Here are some key findings from a five-year assessment
of 5,732 children in 73 schools done by the state
Department of Health using standards developed by the
Association of State and Territorial Dental directors:
Children enrolled in Medicaid were 32 percent more likely
to have "caries experience" than those not enrolled.
However, children in the Medicaid group showed no
significant difference in untreated caries from
those in the general population. The same held true for the
treatment urgency summary. Rates were the same as those for
the privately insured population. And children enrolled in
Medicaid were more than 35 percent more likely to have
sealants than non-enrolled children. The study concluded
that "parent involvement and transportation" were the big
drivers of utilization of care, not the availability of
dentists, and not income level.
This is not to say that workforce isn't a significant
factor, one that can positively affect the oral health of
the underserved. Ten years ago, the South Carolina Dental
Association received a Robert Wood Johnson Foundation grant
to test patient navigators. We targeted counties with few
dentists and low utilization. The navigators were from the
target communities and knew who needed care. They helped
patients make and keep appointments and follow-up
appointments when indicated. With very little money and
very little training time, utilization rates increased to
match those of surrounding counties.
We now provide training for school nurses and have
created a new position, the Community Oral Health
Coordinator. The issue was not the availability of
dentists. Multiple factors—chiefly logistical and
administrative barriers and lack of oral health literacy—were creating oral health crises in pockets of the state.
The introduction of these simple and low-cost innovations
helped these communities lift themselves up to a better
state of oral health.
South Carolina's Rural Dental Incentive plan helps repay
student loans for dentists who locate in designated areas
and treat Medicaid patients for three years. Most of the
participating dentists have stayed beyond that three-year
We started a free clinic using senior dental students on
a rotation to provide free, comprehensive care. We use a
technical college's hygiene department and space at the
free medical clinic. Supplies are donated and local
dentists donate their time as adjunct faculty. A mobile
dental unit donated by a hospital allows us to travel to
nursing homes and other locations. We plan to add a
hospital rotation to help with pre-surgery oral health
issues and collaborate on oral systemic research with
diabetic patients. Medical University of South Carolina
(MUSC) College of Dental Medicine Dean Jack Sanders, DMD,
says these programs help the students "grow their hearts"
for community commitment.
The key is not the number of dentists; it is treatment
capacity. The decades-old ratio of 1:2,000 is out of date.
The Health Resources and Services Administration standard
is now 1:5,000. Advances in technology and practice
efficiency, along with increases in both the number and
scope of practice of auxiliaries within the dental team,
have increased the oral health system's capacity to deliver
care. Microeconomics 101 tells us not to increase capacity
until we maximize our existing production. In a March 2011
national survey by the Academy of General Dentistry, more
than 50 percent of the dentists said they could take on as
many as 11 percent to 25 percent more patients with the
capacity they already have.
If there is not a shortage of dentists, then why doesn't
everyone get care?
Without insurance, cost can be a barrier. If you need
help making appointments, just finding a dentist can be a
barrier. If you lack basic oral hygiene, disease is almost
inevitable. If you feel stigmatized by oral disease, you're
a lot less likely to seek help. If you can't get a ride to
the dentist, or time off from work, or find someone to
watch the kids, you can't get care. Increasing workforce
size does nothing to address those basic needs. Most of the
factors separating patients —or more accurately, people
who should be patients—from dentists are not in our
control. The real barriers to care, or drivers for
utilization for care, reside in the realms of education,
social services, societal and cultural norms, ancillary
needs such as transportation or child care, a systemic
failure to value oral health, and, ultimately, the
financial commitment to overcome these barriers.
Canada and New Zealand have learned the hard (and
expensive) way that therapist programs oriented almost
exclusively toward restorative procedures did not reduce
the caries rate. Without educating patients, instilling a
sense of the value of oral health, implementing widespread
prevention programs, providing the ancillary support that
people need to participate in the oral health system and—sorry, folks—coming up with the funding needed to make
all of that happen, all the therapists in the world will
not create health. Think again about obesity. Would anyone
in his right mind suggest that the way to control that
epidemic is to train non-physicians to perform
Remember that our goal is the best possible oral health
for as many people as possible. We need to quit arguing
about whether therapists might hurt patients or what the
definition of access is. Existing, available services are
underutilized for multiple reasons. Focusing only on
untreated disease leads, I believe erroneously, to the
conclusion that we need more people to fill and pull more
teeth. We need better information for our diagnosis.
Midlevel providers have after decades failed to improve the
oral health of the underserved populations or save money in
the very countries that their advocates hold up as shining
successes that should be replicated here.
Positive workforce ideas like patient navigators,
programs that train school nurses and physicians to assess
risk and refer to dentists, and expanded function
auxiliaries are all proven successes. They promote oral
health by empowering people to take care of themselves.
They bring people into a proven system based at its heart
on the doctor-patient relationship, and are very cost
We have made significant progress in South Carolina.
Much work remains. The biggest barrier of all is the need
for societal recognition of the value of oral health and
that oral health is achievable for all those who seek it.
Creating a second tier of care is a treatment plan based on
a faulty diagnosis. You cannot cure what you