Letter to Editor

Thank you for your special issue “Dentistry and the Aging Population” (October 2017). We wholeheartedly agree that preparing dentistry to treat the “older” adult patient is extremely important. Also important is how the United States is going to come to grips with paying for all healthcare, and reaffirming dentistry’s role in reducing chronic disease burden thus reducing overall cost as our population ages and many enter into long-term care.

We would like to comment on Dr. Catalanotto et al article entitled, “Emerging Models of Dental Practice Aim at Addressing Needs of the Aged.” The article assumes that, “there is a Medicare dental benefit in the future.” Though a Medicare dental benefit would be helpful in reducing chronic disease burden among older adults by enabling them to better care for their teeth, it is not imminent. Many states have limited or no adult Medicaid dental benefits, which makes it even harder for patients with the greatest need for oral care to acquire a dental home. The article considers, “whether the oral health workforce will have the capacity to care for the additional millions of newly insured who will seek care.” We believe that workforce supply must be evaluated state by state to determine which models would be most appropriate for each state. The Association of State and Territorial Directors (ASTD) in November 2015 published a “Best Practice Approach Emergency Department Referral Programs for Non-Traumatic Dental Conditions.” One of the five best practices put forward was from our home state of Maryland and illustrated the proven success of Community Dental Health workers, showing a 25% decrease in emergency department dental visits. Dental therapists cannot make the same claim. It is unfortunate that Community Dental Health Coordinator (CDHC) workers were not even mentioned a s cost-effective solution, proven and implemented already with lower costs to train these highly effective members of the dental team. In addition, many states have increased dental school enrollment or opened new dental schools in anticipation of this need. Access to a fully trained dentist in many states is not a contributing factor to people not seeing a dentist. The bigger factor we find is poor oral health literacy and a mechanism to pay for the care they deserve.

The article goes on to state that dental health aid therapists are a “cost effective strategy to expand the dental workforce while making it more culturally diverse.” A visit to any dental school will show the great strides dentistry has taken to achieve cultural diversity over the last decade, with women and minorities making the majority of dental students today. Dentists are trained to provide specific care that is needed by many patients, including the medically and/or mentally compromised patient and the very frail older patient. The proposed “dental therapist” provider sets up the potential for a two-tiered dental healthcare system where some adults are relegated to a lesser standard of care. The article goes on to state an unpublished study (reference 13) that estimated nearly 60% of procedures performed by dental therapists on-site were restorative. It is our experience in treating long term care patients for many years the quoted percentage of restorative treatment is too high, particularly for the medically compromised patient. Our emphasis has been on periodontal and preventative treatments, which are well within the scope of a dental hygienist in consultation with the supervising dentist and medical team. Pneumonia is a particular concern for these patients, and our focus should continue to be removal of the biofilm of the oral cavity to reduce risk of aspiration. The article also neglected to mention the exciting potential of arresting caries with the use of silver diamine fluoride on the frail patient with dental caries.

The Minnesota dental therapist model may have worked over the past ten years in Minnesota, but other states have concerns.

1. Minnesota remains at or near the bottom of states in the payment rate for adult Medicaid services

2. Currently there are 77 licensed dental therapists in Minnesota, with only a small percentage working in a Census-designated rural county.

3. Minnesota adults are stills seeking dental treatment in emergency rooms are rising, costing taxpayers an estimated $148 million over the past three years

4. More than half of children enrolled in the Minnesota state healthcare program received no dental or oral health services

5. The Minnesota model currently is an expansion of the scope of the duties of a dental hygienist.

6. Reimbursement for a dental procedure in Minnesota is the same for a dental therapist as it is for a dentist – no cost effectiveness.

In Maryland, an ADA Health Policy Institute study has shown our emergency department dental visits are decreasing. Our percentage of children on Medicaid receiving dental services is over 60%.

Currently, dental hygienists play a very important role in providing care to elderly patients, whether it is in our office, by indirect supervision in a long-term care facility, or tele-dentistry from a remote location. An article in the Journal of Public Health Dentistry by Nash et al (September 2017) states that converting dental hygienists to dental therapists “does not actually increase the size of the workforce.” The article goes on to state that “Additionally, it potentially diminishes the time available for dental hygienists to care for adults with periodontal disease.

Since the “Access to Care” issue is complicated and multifactorial, we feel the answers need to address many factors. In Maryland, we are very excited about the proven success of Community Dental Health Coordinators (CDHC) in our state and believe they are our best solution along with reauthorizing our adult dental Medicaid benefit to continue to lower our emergency department dental visits and provide dental homes to more patients. Our finding suggest that many patients need assistance to navigate the current complicated healthcare system including that of dentistry, and that is especially true of the elderly. CDHC’s have the education to go out into the community and help patients obtain the dental care they need. Whether it is assisting a long-term facility filing the paperwork for an incurred medical expense or instructing a nurse’s aid or family member how to best provide daily oral care, CDHC have the potential to help patients access dental care system. As recognized in the ASTDD Best Practice Report in Maryland, dentists have piloted one of the most successful CDHC Medicaid spending for non-productive emergency department visits and lowered the number of opioids prescribed in the community for potential abuse. To leave out mention of CDHC as a potential possible contributing solution to care for the aging population was an oversight that we felt compelled to correct.

Charles A. Doring, DDS, MAGD
Diane Romaine, DMD, MAGD

Response From Authors

By relying on flawed data, the American Dental Association’s (ADA) Health Policy Institute (HPI) recently released report, “Geographic Access to Dental Care,” severely overestimates the availability of dentists to treat the publicly insured.

The lack of access to oral health care is a serious issue in our country. One only needs to read the recent Washington Post story about adults standing in line for hours to get care to get a picture of real life for too many Americans. More than 50 million children and adults—nearly 40 percent of U.S. children—rely on Medicaid as their dental insurer. If we are truly going to understand the magnitude of the oral health access problem for the publicly insured, and to respond accordingly, we need to rely on facts. Here’s how the ADA report minimizes the size of the access problem:

The 50-state report uses geomapping and national census data to estimate the geographic distance between publicly insured children and dental providers that are listed as being enrolled in Medicaid. To determine which dentists see children on Medicaid, the report relies on Insure Kids Now (IKN) – a national website with state-submitted data that lists dentists who registered for Medicaid and the Children’s Health Insurance Program (CHIP).

There are a number of flaws in this list that make it a highly unreliable source with which to base estimates. A 2015 attempt by ADA to contact a sample of IKN dentists to verify the list’s reliability found that nearly half (48%) of dentists did not practice at the location listed in the IKN database. So the error rate on which HPI maps locations of Medicaid participating dentists is extremely high.

Equally important is what the list doesn’t tell us. Dentists are only asked if they enrolled in Medicaid/CHIP, not how many children they served, or if they served any at all.

Here is how these flaws play out. In Florida, for example, the IKN database says that 30% of dentists were enrolled in Medicaid or CHIP in 2014. But a 2013-2014 health department survey of dentists found that fewer than 23% of dentists reported treating any Medicaid patients and, only 15% reported taking new Medicaid patients. A meager 10% of Florida dentists reported treating at least 125 Medicaid patients. Meanwhile, in 2014, nearly 70% of Florida children on Medicaid went without a dental visit. Still, the ADA-HPI report says that 96% of publicly insured children live within 15 minutes of a Medicaid dentist. In Iowa, according to the state’s IKN list, Medicaid dentist participation was 86% in 2014. But a survey conducted by the University of Iowa the previous year found that only 16% of private practice dentists accepted all new Medicaid patients, 42% placed conditions on accepting new Medicaid patients, and 42% would not see any new Medicaid patients. Yet ADA’s latest report states that 93% of publicly insured children live within 15 minutes of a Medicaid dentist in Iowa.

The assumptions ADA uses to estimate Medicaid dentist “shortage areas” are also highly questionable. Looking again at Florida, the report estimates that 85% of publicly insured children live in areas where there is at least one Medicaid dentist per 2,000 publicly insured children within a 15-minute travel time. A 1:2,000 population ratio would represent a reasonable caseload if each dentist were only to treat Medicaid patients. But, as the above data reveal, most Florida dentists serving publicly insured children are also serving other patients; in fact, most dentists serving publicly insured patients serve a majority of patients that are not publicly insured.

Whether dentists are enrolled in Medicaid and CHIP doesn’t begin to tell us whether the publicly insured can be seen for care. And estimating dentist-to-Medicaid patient ratios based on the assumption that dentists on the IKN list are serving only publicly insured patients is misguided. Claiming that 98% of publicly insured children live within 15 minutes of a Medicaid dentist is a willful and dangerous misuse of basic data. Further, the IKN list only identifies dentists who have enrolled to treat Medicaid children, not adults. The number of Medicaid adults with access to a dental benefit has grown by millions as 23 states now offer at least limited dental care to both the traditional Medicaid adult population as well as the expansion group of low-income childless adults. ADA’s geomapping tells us nothing about dentist availability to treat Medicaid adults. Here’s the tragedy: ADA’s overinflating the availability of dental care for Medicaid children may steer state policymakers away from measures they need to consider to improve access for this population. Our low-income citizens deserve better.

Frank Catalanotto, DMD
Jane Koppelman, MPA
Judith Haber, PhD, APRN, FAAN