Addressing Disparities in Oral Health

An integrated approach is needed to open the door to truly equitable care

Heidi Geller

In a 2022 global oral health status report, the World Health Organization reported that globally, three out of every four people (more than 4 billion) who live in low-and middle-income countries suffer from oral diseases, the most common of which are dental caries, severe gum disease, tooth loss, and oral cancer.¹ An individual's oral health is a vital indicator of his or her overall health and well-being. However, the goal of achieving equity in oral healthcare regarding access to care and the quality and affordability of care has been thwarted by racial, ethnic, and socioeconomic factors, and 77 million Americans have no dental coverage.^2,3

Oral health is an oft-neglected component of healthcare in the United States. People who are low-income, members of a racial or ethnic minority, living in a rural or underserved area, or medically fragile, elderly, or disabled are the most likely to experience difficulties accessing quality care.^4,5 "The national conversation on oral health needs to be person-centered and focused on prevention," says Nader Nadershahi, DDS, MBA, EdD, dean of the University of the Pacific Arthur A. Dugoni School of Dentistry, and outgoing chair of the American Dental Education Association (ADEA). "We achieve this when financial and social access takes an integrated approach to oral health, overall health, and mental health."

An Oral Health Crisis

Although efforts by lawmakers to add full dental benefits to Medicare in 2022 failed, the US Senate renewed the push in March 2023 during a hearing held by the Senate Finance Subcommittee on Health Care. "Certainly, we have made progress in improving oral healthcare for children, especially for vulnerable children. But for working-age adults and seniors, disparities in oral health outcomes and in access to dental care have widened by income and race," said Senator Ben Cardin (D-MD), the subcommittee's chair. "Treating dental care as essential in US health policy—for all ages, not just children—is the only way to address these disparities."⁶

Other witnesses during the hearing named workforce diversity and size, geography, and education as barriers to dental care across the United States. "It is well established that a person's healthcare and trust in the medical community improve when they are seen by a provider of their own choice," said Cherae Farmer-Dixon, DDS, MSPH, dean of the Meharry Medical College School of Dentistry.⁷

In a study conducted by the Oral Health Workforce Research Center, the researchers emphasized that "improving the racial and ethnic diversity of the nation's dentists is critical in efforts to reduce disparities in access to care and health outcomes and to better address the oral health needs of an increasingly diverse US population."⁸

Disparities in Oral Health Equity

The challenges posed by the COVID-19 pandemic focused attention on the weaknesses in the nation's healthcare system as well as its underlying structures that perpetuate inequities in health. For many Americans, the emergency room is the only access point for dental and oral healthcare. "There are more than 2 million emergency hospital room visits per year in America for oral health conditions," Marko Vujicic, PhD, chief economist and vice president of the Health Policy Institute at the American Dental Association, said at the Senate hearing. "If you do the math, that's about one every 15 seconds. This is heartbreaking, but as an economist, I also want to highlight that this costs our healthcare system upward of over $2 billion per year."⁷

In a 2022 survey of 5,682 adults, the CareQuest Institute for Oral Health found that people of color and those who have lower incomes bear a disproportionate burden of oral disease and disproportionately lack access to needed care. Key findings from the survey include the following:³

• Lack of insurance compromises overall health. Of the respondents without dental insurance, 25.1% reported that their overall health became worse during the past year, compared with 19.9% of those with dental insurance. Furthermore 11.5% of the respondents without dental insurance rated their oral health as poor, compared with 5.5% of those with dental insurance.

• Cost deters care seeking behavior. Cost was the top reason that participants cited for not seeking oral care. Approximately 40% of the respondents without dental insurance cited cost as the reason they've forgone going to the dentist during the past 2 years, compared to 14% of the respondents with dental insurance.

• Race and ethnicity may affect health. People of color are less likely to have dental insurance and are more likely to have unmet dental needs when compared with White Americans. They also may face discrimination and excessive costs in receiving oral healthcare.

What Can Be Done?

Oral conditions and certain medical conditions, such as diabetes, stroke, heart disease, kidney disease, and cancer, often share common risk factors, and with the well-established link between oral health and systemic health, preventive oral care is now viewed by many as an essential component to maintaining overall health and wellness. "Most healthcare focuses on treating what's already happened," says Kaz Rafia, DDS, MBA, MPH, CareQuest Institute's chief health equity officer. "To make headway in improving health equity, an upstream approach is necessary that medically connects oral health with overall health."

Medicare/Medicaid Expansion Efforts

In November 2022, the Centers for Medicare and Medicaid Services (CMS), used its authority to expand dental coverage for medically necessary oral healthcare services—a notable step toward expanding dental coverage for beneficiaries in Medicare's Part A and B plans.⁹ The final rule, which was published in the November 18, 2022, Federal Register and took effect January 1, 2023, expanded coverage to include oral care that eliminates infection preceding an organ transplant and certain cardiac procedures. Coverage for oral health services associated with head and neck cancers will go into effect in 2024. The final rule also includes a framework for an annual review process, creating future opportunities to submit additional oral health procedures for consideration under the mandate.

Although these steps to expand care for certain medically necessary procedures are victories, pursuing legislation to codify dental care services for Medicare and expand coverage under Medicaid remains on the agenda with good reason. Nearly 72 million people live in America's 12,238 "dental deserts," according to the most recent data from the US Department of Health and Human Services' Health Resources and Services Administration, and these numbers increase every year.¹⁰

After the March 2023 Senate Finance Subcommittee on Health Care hearing, Cardin and Senator Robert Casey Jr. (D-PA) introduced legislation that would allow Medicare to cover dental, vision, and hearing services as well as increase the federal investment in Medicaid covering these services. Cardin called out the worse outcomes for people with diabetes or heart disease or who require hospital emergency room visits for dental care as costly to taxpayers. "We are paying more in our healthcare system because of these disparities," he said. "One study found that the United States could save $22.8 billion annually by improving oral healthcare."⁶

A more recent bill, the Medicare for All Act of 2023, which was introduced jointly in May 2023 by Senator Bernie Sanders (I-VT) and Representatives Pramila Jayapal (WA-07) and Debbie Dingell (MI-06), proposes comprehensive Medicare benefits, including oral healthcare, to every person in the United States.¹¹ This new bill follows previous "Medicare for All proposals," which faced obstacles regarding costs.

CMS's Annual Review Process

Now that CMS will undertake an annual review process per its final rule, additional oral and dental procedures can be considered for coverage under Medicare as medically necessary, which will provide a mechanism to further improve the nation's oral and overall health going forward. One entity that is all too familiar with the process is the Santa Fe Group, a think tank comprised of dental and medical healthcare providers, educators, and scientists that has taken on, among other critical oral health issues, the goal of adding a complete dental benefit to the Medicare program. Before CMS published the November 18, 2022, final rule, the Santa Fe Group had been providing the agency with scientific evidence from insurance studies, industry practices, and other research that demonstrated the relationship between the provision of preventive oral healthcare and reductions in overall healthcare costs.

One such study used data from the New York State Medicaid program.¹² This study was particularly relevant because the New York State Medicaid program includes the most extensive adult dental benefit package of any Medicaid program in the United States, and it has approximately 4 million adult members. Moreover, its members are racially and ethnically diverse and demonstrate a high prevalence of comorbidities and oral disease. Looking at the big picture, the researchers examined the relationship between the receipt of dental services and all-cause emergency room visits and inpatient admissions as well as reduced healthcare costs. The data revealed that preventive dental care was associated with better healthcare outcomes, most notably regarding the rates and costs of inpatient admissions. Ira B. Lamster, DDS, MMSc, dean emeritus of the Columbia University College of Dental Medicine, was one of the study's researchers. "The separation between dentistry and medicine in Medicare goes back to 1965, however there is a lot of evidence that the separation shouldn't exist," he says. "Perhaps the best evidence is that oral infections may precipitate chronic diseases."

Another clinical study reviewed by CMS during its rulemaking examined the link between healthcare costs and preventive dental care protocols among diabetes and coronary artery disease patients who were members of a large Arkansas commercial dental plan.¹³ This 5-year study also produced evidence that the provision of preventive dental care results in significant average yearly healthcare cost savings. The ranges of these savings were progressively higher depending on whether patients had only diabetes ($515 to $574), only coronary artery disease ($548 to $675), or diabetes and coronary artery disease ($866 to $1,718).

Currently, CMS is taking nominations for additional medically necessary dental procedures to add coverage for in its CY 2024 Medicare and Medicaid programs final rule. In February 2023, the Santa Fe Group nominated medically necessary dental care procedures for diabetes and blood and solid tumor cancers.¹⁴

Solutions for Diversifying the Workforce

The demographics of dentistry are changing, but work remains that can potentially help to reduce disparities in oral health. At a 2023 symposium hosted by the University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, California, participants explored the health equity factors influencing and impacting oral healthcare. Speakers noted that the racial mix of the dentist workforce does not reflect that of the US population and that Black and Hispanic dentists are significantly underrepresented in the profession.¹⁵

According to the most recent data from the American Dental Association's Health Policy Institute, Black Americans comprise an estimated 12.4% of the population and approximately 3.8% of the dental workforce whereas Hispanic Americans comprise an estimated 18.4% of the population and approximately 5.9% of the dental workforce. The proportion of White students in dental schools is decreasing while Asian and Hispanic student numbers are growing; however, almost all of the diversification in the profession is accounted for by Asian dentists. The share of Black dentists—who are represented by less than four of every 100 dentists nationwide—has been relatively stagnant for the past 15 years.¹⁶

Although the industry and academia are tackling this issue by initiating pipeline programs as early as prekindergarten, addressing implicit bias in admissions, and increasing cultural competency training, the rising price of attending dental school remains a significant barrier. Educational debt may impact the decision to attend as well as dentists' career decisions after graduation. According to ADEA, in 2022, 83% of dental students graduated with educational debt and the average debt per graduate was $293,900.¹⁷

Stakeholders across the industry continue to urge the US Congress, state legislatures, and state dental associations to pass measures to reduce student loan interest rates, provide refinancing opportunities for borrowers, and offer opportunities for loan forgiveness, scholarships, grants, and tax deductibility.

Technology Mobilizes Oral Healthcare

Shortages of dental healthcare professionals greatly impact rural and underserved communities where traveling long distances for care is unavoidable. Kwane Watson, DMD, a dentist from Louisville, Kentucky, turned serial entrepreneur, understands the obstacles facing these geographies. Having owned and sold two practices and worked as a Medicaid provider, he's witnessed firsthand the difficulties that patients experience coordinating their schedules to make an appointment as well as the financial cost to the providers when the patients need to cancel or do not show.

To address these issues, Watson launched Kare Mobile, a dental service organization focused on the delivery of direct-to-consumer oral care. Established in 2019, the business builds, operates, and licenses state-of-the-art mobile dentistry clinics that make oral healthcare more accessible for patients with Medicaid and more profitable for the providers who deliver it. The low overhead costs allow these mobile units to deliver oral healthcare to rural and urban communities where dentists are scarce.

"The launch of our mobile dental division was a huge success and a turning point for our company as we became the first mobile dental service organization that develops, designs, and manufactures proprietary vans with technology enabled by software that allows providers to optimize their routes, which increases efficiency and profitability," Watson says. "Most importantly, Kare Mobile patients receive comprehensive, safe, and ultraconvenient treatment. We are not only disrupting the dental industry but also improving trusted access to dental care."

A New Model of Care

During Farmer-Dixon's Senate subcommittee testimony, she shared a message of optimism regarding the improvements in general health and well-being achieved during the past century in the United States, noting that Americans are living longer and healthier lives. She also recognized the significant breakthroughs that have occurred in the diagnosis and treatment of oral diseases; however, she noted that not all have benefited. "If we want to adequately combat and eliminate oral health disparities, we must meet communities where they are," she said.

Could advancing health equity serve as a catalyst for the progression of the systemic health model and the interoperability of healthcare information systems? According to Mark Greenstein, executive vice president and chief growth officer for Heartland Dental, more than half of the people going into the Medicare system are choosing Medicare Advantage programs, which increasingly come with dental benefits. "In Medicare Advantage, people are realizing that the dental office can be a front door to the healthcare system," he says. "They may not go to their primary care physician if they're feeling well, but they go to the dentist twice a year. That dentist may be the first person to discover that they have hypertension and ought to go see their primary care physician about it."

David Kochman, vice president and chief corporate affairs officer for Henry Schein agrees. "Fundamentally, we are trying to promote prevention and wellness," he says. "To lift up the primary care model itself and to treat it as patient-centric rather than profession-centric will help to close those health equity gaps in a formidable way."

References

1. Global Oral Health Status Report: towards universal health coverage for oral health by 2030. World Health Organization; 2022.

2. Oral Health in America: Advances and Challenges: Executive Summary. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2021.

3. CareQuest Institute for Oral Health. State of oral health equity in America 2022. CareQuest website. https://www.carequest.org/SOHEA2022. Published April 2022. Accessed July 31, 2023.

4. American Dental Association Health Policy Institute. Oral Health and Well Being in the United States. ADA website. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/us-oral-health-well-being.pdf. Published May 2016. Accessed July 13, 2023.

5. ADA health equity toolkit and action plan 2022-2025. ADA website. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/community-initiatives/health-equity/health-equity-toolkit-and-action-plan-2022-2025.pdf. Updated September 15, 2022. Accessed July 31, 2023.

6. An oral health crisis: identifying and addressing health disparities Senator Cardin opening remarks. Ben Cardin U.S. Senator for Maryland website. https://www.cardin.senate.gov/press-releases/an-oral-health-crisis-identifying-and-addressing-health-disparities-senator-cardin-opening-remarks/. Published March 29, 2023. Accessed July 13, 2023.

7. Hanson M. Maryland's Cardin, other Democrats, push to include dental coverage under Medicare. Ben Cardin U.S. Senator for Maryland website. https://www.cardin.senate.gov/news/marylands-cardin-other-democrats-push-to-include-dental-coverage-under-medicare/. Published March 31, 2023. Accessed July 13, 2023.

8. Raja Z, Wides C, Kottek A, et al. The evolving pipeline of Hispanic dentists in the United States: practice and policy implications. Oral Health Workforce research Center website. https://www.oralhealthworkforce.org/wp-content/uploads/2017/09/OHWRC_Evolving_Pipeline_of_Hispanic_Dentists_2017.pdf. Published August 2017. Accessed July 31, 2023.

9. Freed M, Neuman T, Cubanski J. How the 2023 Medicare physician fee schedule final rule changes Medicare coverage of dental services. KFF website. https://www.kff.org/medicare/issue-brief/how-the-2023-medicare-physician-fee-schedule-final-rule-changes-medicare-coverage-of-dental-services/. Published December 8, 2022. Accessed July 13, 2023.

10. Health Resources & Service Administration. Health workforce shortage areas. HRSA website. https://data.hrsa.gov/topics/health-workforce/shortage-areas. Updated August 30, 2022. Accessed July 31, 2023.

11. Kornish L. Sen. Bernie Sanders renews push for Medicare for All to end ‘totally broken' health-care system. CNBC website. https://www.cnbc.com/2023/05/17/sanders-pushes-medicare-for-all-to-end-totally-broken-health-system.html. Published May 17, 2023. Accessed July 13, 2023.

12. Lamster IB, Malloy KP, DiMura PM, et al. Dental services and health outcomes in the New York State Medicaid program. J Dent Res. 2021;100(9):928-934.

13. Borah BJ, Brotman SG, Dholakia R, et al. Association between preventive dental care and healthcare cost for enrollees with diabetes or coronary artery disease: 5-year experience. Compend Contin Educ Dent. 2022;43(3):130-139.

14. Nominations for medically necessary dental treatment coverage. Santa Fe Group website. https://santafegroup.org/news/medicare/nominations-for-medically-necessary-dental-treatment-coverage/. Published February 24, 2023. Accessed July 13, 2023.

15. Dugoni School symposium explores how to reduce inequities in oral health care. University of the Pacific website. https://dental.pacific.edu/pacific-newsroom/dugoni-school-symposium-explores-how-reduce-inequities-oral-health-care. Published January 27, 2023. Accessed July 13, 2023.

16. American Dental Association Health Policy Institute. Racial and ethnic mix of the dentist workforce in the U.S. ADA website. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpigraphic_0421_1.pdf. Published April 2021. Accessed July 13, 2023.

17. Dental student debt. American Student Dental Association website. https://www.asdanet.org/index/get-involved/advocate/issues-and-legislative-priorities/Dental-Student-Debt. Accessed July 13, 2023.