Author: Dr. Zachary Brian

The connection between oral health and overall health is increasingly clear, but you wouldn’t know it looking at the federal government’s Medicare program. Medicare, which provided health insurance for more than 62 million U.S. retirees and people with disabilities in 2020, does not include dental coverage — except in very limited circumstances.

Overall, according to a 2019 study by the Kaiser Family Foundation (KFF), 47 percent of Medicare beneficiaries do not have dental coverage. While some Medicare beneficiaries have a dental benefit through optional, add-on Medicare Advantage plans (with additional premiums and co-pays), the scope of coverage is often extremely limited. For much of the older adult population in the United States, oral health care services are simply unaffordable.

A Public Health Emergency

The lack of Medicare dental coverage and high out-of-pocket costs facing older U.S. adults with oral health needs represent a true public health emergency. Forty-seven percent of Medicare beneficiaries did not have a dental visit in the last year, according to the same KFF study. The impact is especially disproportionate for marginalized communities, with the percentage without a dental visit climbing to 68 percent for Black beneficiaries, 61 percent for Hispanic beneficiaries, and 73 percent for low-income beneficiaries. Other at-risk populations are similarly affected. Among Medicare beneficiaries in fair or poor health, for example, the number is 63 percent.

The consequences are as devastating as they are preventable. A study by KFF of the 2016 Medicare Current Beneficiary Survey (MCBS) found that among all Medicare recipients living in the community, “18 percent have some difficulty chewing and eating solid foods due to their teeth.” This includes 29 percent of low-income recipients and 33 percent of recipients with disabilities under age 65. Oral health conditions are also common among the Medicare population: over 14 percent of older U.S. adults have untreated dental decay (caries), and 68 percent have periodontal disease (gum disease).

Various studies have linked periodontal disease to systemic health problems like diabetes, heart disease, kidney disease, and cancer. Dr. Lisa Simon and Dr. William Giannobile said it well in a recent opinion piece appearing in the New England Journal of Medicine: “The key reason that access to dental care is crucial is that, even in the absence of other medical complications, dental problems are a preventable and far-too-common source of disabling disease.”

That reality is especially true for older adults. “Growing evidence shows that poor oral health can worsen health conditions disproportionately impacting older individuals such as diabetes and cardiovascular disease — conditions that Medicare does cover,” the National Dental Association stated in a September letter calling for the expansion of Medicare to include a dental benefit.

A Historic Opportunity

In the decades since Medicare’s establishment in 1965, advocates have continually pushed for expanding the program to include dental, hearing, and vision benefits. However, current political realities mean that reform is perhaps closer than ever before. Powerful interest groups nevertheless threaten to dramatically scale back or derail the proposed change.

“Means-Testing” for Medicare Dental Benefits: A Costly Mistake

Despite not necessarily opposing a dental Medicare benefit altogether, some interest groups are applying the brakes. Rather than make dental coverage universal for all Medicare recipients, some have endorsed a model in which Medicare dental benefits would be available only to beneficiaries whose incomes are 300 percent or less of the federal poverty level (FPL), equating to roughly $38,000 per year for an individual.

To be clear: this would be a mistake. “Means-testing” has never been used with other health coverage under Medicare and would represent a step in the wrong direction if applied to a new dental benefit.

An Inequitable, Potentially Destabilizing Solution

By means-testing dental Medicare benefits, oral health care would remain out of reach for millions of working and middle-class older adults. That’s because out-of-pocket costs for dental care would still exceed many individuals’ available discretionary income, even for those earning more than 300% FPL. After all, KFF reports that out-of-pocket spending on dental care was $874 on average for Medicare beneficiaries using dental services in 2018 and that one in five Medicare beneficiaries using dental services spent more than $1,000 out-of-pocket. Many seniors, the majority of whom live on fixed incomes, simply cannot afford the out-of-pocket costs associated with routine, preventive dental care, to say nothing of more costly restorative or surgical procedures.

Beyond this inequity, however, means-testing dental benefits could potentially threaten the sustainability of the broader Medicare program. Max Richtman, president and CEO of the National Committee to Preserve Social Security and Medicare, noted in a recent op-ed that “If means-testing results in Medicare becoming increasingly unfair to higher-income beneficiaries, they may opt-out and purchase their policy on the private market. The departure of higher-income beneficiaries, who tend to be younger and healthier, would weaken the risk pool, putting additional strain on Medicare’s finances.” Further, as Richtman writes, applying the first-ever means-test to a Medicare benefit would set a dangerous precedent for future means-testing of other coverages.

Moreover, applying a means test to Medicare dental benefits would likely result in a situation in which a majority of private practice dentists decline to participate. We’ve seen this happen with Medicaid and the Children’s Health Insurance Program (CHIP). By limiting the potential pool of new patients, means-testing a Medicare dental benefit would similarly and significantly reduce the financial incentive for private practice dentists. According to the ADA Health Policy Institute (HPI), only 43 percent of dentists nationwide participate in Medicaid or CHIP, dramatically limiting access to care and fueling health disparities among disadvantaged populations. A means test applied to Medicare would almost certainly compound the problem.

The Bottom Line

Dental coverage under Medicare is sorely needed, but to make Medicare dental benefits anything but universal diminishes the message that public health-minded dentists have fought so hard to advance: that oral health is overall health. It also threatens to deepen inequities and deny care to at-risk populations that need it most. Congress should act now to expand Medicare to include dental coverage and reject misguided attempts to impose means-testing on potential beneficiaries.

Dr. Zachary Brian is the Director of North Carolina Oral Health Collaborative (NCOHC) and VP of Impact, Strategy, and Programs for its parent organization, the Foundation for Health Leadership & Innovation (FHLI).

In order to build a more equitable oral health care system for all North Carolinians, it is paramount to pursue policies that encourage the development of a more diverse oral health care workforce.

The pursuit of equity can’t only focus on the patient side of the equation—those who either can or cannot access the care they need. The dental profession has historically struggled with equity, both among patients being able to access the care they need, and among those who train and enter the industry as dentists and other oral health professionals.

White males still represent the majority of dentists, while white females have long dominated the dental hygiene profession. Disproportionate representation by race, ethnicity, and gender is especially predominant among North Carolina dentists and hygienists.

In this blog post, we’ll take a look at the current demographic makeup of the oral health care workforce in the U.S., and in North Carolina specifically. We’ll discuss why provider diversity is so critical and outline potential policy solutions for developing a workforce that looks like the patients it serves.

The Importance of Diversity in the Oral Health Care Workforce

Why does diversity in the oral health care workforce matter?? The answers are many. Research suggests that more diverse racial, ethnic, and gender representation among dental providers can dramatically reduce barriers to access for the underserved and improve oral health care utilization and outcomes.

“Increasing diversity in the dental workforce is more than just the right thing to do,” said Dr. Zachary Brian, director of the North Carolina Oral Health Collaborative. “Its positive impact is also backed by evidence, with greater provider diversity helping increase access and improve utilization and outcomes, particularly for our most underserved communities.”

 

Racial Diversity: A Means to Improve Access, Utilization, and Outcomes

A recent report by the Oral Health Workforce Research Center found 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 U.S. population.”

Research shows that dental health is worse in communities of color, and it has also been demonstrated that patients are more comfortable receiving care from a provider of their own race.

The impact of systemic and interpersonal racism on oral health care is also frequently overlooked: a 2019 study found that “dental visits were less common among those who reported racial discrimination while using the healthcare system or reported emotional impact of discrimination than those who did not.” The same study concluded that “those who experienced the emotional impact of racial discrimination were 25% less likely to have visited the dentist in the past year than those without such experience.”

Studies have also determined that non-white dentists care for a disproportionate number of at-risk patients in minority and underserved communities. Researchers have found that 53 percent of clinically active Black dentists reported primarily treating underserved patients at their primary practice, and another study concluded that “the Hispanic/Latino (H/L) dentist workforce is a critical component of our dental delivery system and is shown to contribute to improved access for H/L populations and underserved populations.”

Increasing racial diversity within the oral health care workforce is therefore imperative for eliminating access barriers, increasing utilization, and improving outcomes.

Gender Diversity: Increasing Access and Offering New Perspective

While there is less research concerning patient preference regarding provider gender (although we can reasonably infer an effect similar to the one revealed in studies on provider race), female dentists are noted for bringing different perspectives and approaches to the practice of dentistry.

For one, studies have shown that female dentists are more likely than male dentists to practice in urban and public health settings, and they are more likely to treat lower-income patients. These findings suggest that increasing gender diversity in the oral health workforce has the potential to improve access to care for our most vulnerable.

Research also suggests that female dentists may be better at encouraging preventive care than their male counterparts. A study published in the Journal of the American Dental Association found that “female dentists recommended at-home fluoride to a significantly larger number of their patients than did male dentists” and “female dentists also chose to use preventive therapy more often at earlier stages of dental caries.”

There is no question that female dentists bring a fresh perspective to a profession long dominated by men. Writing about the increase in female dentists, Dr. Cindy Roark, a dentist herself, notes in an article for Dentistry Today that “at its most basic level, a diverse leadership team means a healthcare organization will naturally have a greater understanding of the populations it serves.”

Where Do We Stand Today? Diversity Among Dentists and Hygienists

By Race and Ethnicity

People of color are greatly underrepresented among the dentist and hygienist workforces. A 2016 study by the American Dental Association’s Health Policy Institute (HPI) found that just 26.4 percent of U.S. dentists were non-white, despite people of color representing 38.7 percent of the total population.

The disparity is even more stark in North Carolina, where according to a recent study, 81.5 percent of dentists are white, despite white people representing only 64.1 percent of the population. Even more disproportionate, North Carolina’s dental hygienists are 92.5 percent white.

Recent trends are more encouraging. According to HPI, “from 2008 to 2018, the percentage of active white dentists [in the United States] decreased from 78.2% to 71.9%.” While Asian and Hispanic dentists made gains, however, alarmingly, the percentage of Black dentists was relatively unchanged.

By Gender

In addition to being disproportionately white, U.S. dentists are mostly male. According to data compiled by the American Dental Association (ADA), in 2020, 65.5 percent of professionally active dentists were male. Women made up just 35.5 percent. Data derived from the North Carolina State Board of Dental Examiners (NCSBDE) shows that the gap is narrowing in our state, but the disparity remains pronounced.

Among dental hygienists, the gender divide is flipped. While up-to-date data for practicing dental hygienists is hard to come by, the American Dental Education Association (ADEA) reports that 94.7 percent of students currently enrolled in an accredited dental hygiene program are female.

Opportunities for Growth: Supporting Diversity in the Dental Workforce

There is no silver bullet to improve racial and gender diversity in the oral health care workforce. That said, there is no shortage of common-sense, evidence-based policies to help bridge existing gaps and build a dental workforce reflective of the people it serves.

We’ll focus on just two such opportunities in this blog post: early educational interventions and improved recruitment efforts by dental schools.

Early Educational Interventions

Limited awareness of oral health care career opportunities and lack of support for early education and “pipeline” programs present significant barriers to racial minorities and women entering the dental workforce.

Pipeline programs in particular — which provide all-inclusive support in the form of mentorship, scholarships, externships, and/or other opportunities — are fundamental in helping introduce minority students and those from underrepresented communities about dental career opportunities.

Notably, a dental pipeline program funded by the Robert Wood Johnson Foundation made initial grants to 11 dental schools to support community-based education related to opportunities in dentistry for minority and low-income students. A less comprehensive but similar “Saturday Academy” program organized by the NYU School of Dentistry introduces underrepresented minority and low-income high school students to dentistry as a viable career option and offers mentorship.

Policymakers should consider support for similar programs in order to attract a new generation of diverse students to dental education and oral health care careers.

Dental School Recruitment

No less important than efforts to introduce minorities and women to career opportunities in dentistry are dental schools’ own recruitment policies. For too long, dental schools have done little to proactively seek diverse pools of applicants, let alone admit classes that reflect the populations they will one day serve. Researchers have recently noted that “U.S. dental schools’ admission practices present a critical gateway to increased diversity, but the current pipeline of qualified minority applicants is insufficient.”

This is not to say that change isn’t happening. Many dental programs — including North Carolina’s own UNC Adams School of Dentistry and East Carolina University School of Dental Medicine — have taken steps to increase diversity in their dental programs. Data indicate that North Carolina’s dental students more closely mirror the state’s racial composite than does the dental workforce itself. An analysis of dental classes graduating 2015-2019 showed that 36 percent of UNC dental students were non-white, as were 28 percent of ECU dental students.

Potential opportunities to increase recruitment of minority, women, and otherwise underrepresented students by dental schools include, but are not limited to:

• Increasing diversity on the interviewing and admissions teams/committees
• Increasing diversity among faculty and staff
• Emphasizing cultural competency in dental curriculum
• Support for dental pipeline programs
• Mentorship opportunities
• Increased financial assistance and scholarship opportunities

In Conclusion: Moral and Practical Imperatives for Diversity in the Dental Workforce

Policymakers have both moral and practical imperatives to increase diversity in the dental workforce. The cause is just, and the science is clear: racial and gender diversity among oral health care providers increases access and improves both utilization and outcomes.

If we are to build a more equitable and accessible oral health care system for all, it is critical that we support the development of a workforce that reflects the populations it serves.

The North Carolina Oral Health Collaborative (NCOHC) is actively working with stakeholders across North Carolina to help develop a more diverse oral health care workforce. For more information on NCOHC and to get involved, please become a member of our advocacy platform, NC4Change — membership is free and there are many opportunities to engage with our work. Together we can build a more equitable and accessible oral health care system for ALL North Carolinians.

The Next Generation Dental Office is Here

In the 21st century, modern dental practices have evolved to further place the overall health and well-being of the patient at the center through interprofessional collaboration and integration. Most notably, many dental practices now monitor blood pressure, screen for glycemic control, and educate patients on the connection between oral health and chronic diseases such as diabetes, osteoporosis and heart disease.

Will you get your next flu shot at the dentist, too?

In this blog post, we’ll examine the opportunity for dental professionals to improve and protect public health by administering vaccines, particularly for HPV and seasonal influenza.

Vaccinations in the United States: A Brief Background

Vaccinations are a core component in the fight against disease, helping build immunity prior to infection. Today, vaccines are available to help protect against diseases such as tetanus, Hepatitis B, measles, mumps, rubella, and whooping cough, just to name a few. In recent years, effective vaccination even eliminated smallpox.

A list of vaccine schedules outlining what vaccines are recommended at which ages can be found here.

Despite their effectiveness, millions of U.S. residents forgo vaccination each year. Fueled by scientific skepticism, distrust, cost, lack of insurance coverage, and other factors, vaccination rates in the United States are declining. A 2019 study found that between 2009 and 2018, 27 U.S. states reported a drop in the percentage of vaccinated kindergarten-age children.

According to the study, “For diseases with deadly potential … vaccination rates have fallen or remained below ideal thresholds.”

Despite this unfortunate reality, significant opportunities exist to improve and protect public health through vaccination, and oral health professionals can and should be part of the solution.

Dentists and Vaccination

You might be surprised to learn that dentists administer injections far more often than their medical counterparts. Each year millions of patients visit the dentist without visiting a medical provider. According to information from the Agency for Health Research and Quality (AHRQ), in 2017 alone, more than 31.1 million people in the U.S. sought care from a dentist, but not from their physician. According to the American Dental Association (ADA), “approximately 9 percent of Americans see a dentist, but not a physician, annually.”

Because dentists are skilled at administering injections, and they routinely engage with patients who do not frequently visit medical providers, dental visits are a prime opportunity for vaccination.

There is historical precedent for dentists and dental professionals delivering vaccinations as well. During the H1N1 pandemic in 2009, dentists in certain states were permitted to administer vaccinations to help fight on the frontlines of the pandemic response.

In 2019, the Oregon state legislature approved a bill allowing dentists to prescribe and administer vaccines. The law is expected to go into effect later in 2020. Other states that allow dentists to administer vaccinations include Minnesota and Illinois, which permit dentists to deliver the flu vaccine.

Allowing dentists to administer vaccines could have particular significance as the nation prepares to optimize delivery of an anticipated Coronavirus vaccine. According to the American Association of Dental Boards (AADB), at least one half of U.S. states have considered allowing the administration of COVID-19 vaccines by dentists once they become available.

HPV Vaccine and Reducing Oropharyngeal Cancer Risk

Even with scope of practice modifications, the dental office will likely never become a major access point for certain common vaccinations, like those for tetanus and Hepatitis B. However, there is a significant opportunity for oral health professionals to play a key role in providing vaccines for diseases with strong connections to oral health, as well as seasonal vaccinations.

The human papillomavirus (HPV), for example, is the most common sexually transmitted infection in the United States, and it significantly raises the risk of oropharyngeal cancer. According to the Centers for Disease Control and Prevention (CDC), HPV causes an estimated 70 percent of oropharyngeal cancers.

HPV’s connection to oral health means that dental professionals are prime candidates for delivering HPV vaccinations, monitoring vaccine compliance, and providing patient education. Allowing dental professionals to provide these services would increase efficiency and vaccination rates while lowering costs.

Routine vaccinations, including the seasonal flu vaccine and anticipated coronavirus vaccine (which is likely to be required annually), could also be effectively administered by dental professionals, achieving the same objectives.

Federally-Qualified Health Centers (FQHCs), in particular, are excellent sites for providing these vaccines, as dental-medical care is often integrated in pursuit of whole-person health.

Challenges to Dental Professional-Administered Vaccines

This not to say there are not challenges for this model of dental professional-administered vaccination.

Perhaps most significantly, throughout modern history, dentistry has been seen as separate from medicine. Rather than being viewed as an integral part of whole-person health, oral health has been siloed, effectively undermining opportunities to promote vaccination. Unfortunately, there will always be those who push back against further dental-medical integration.

Other, more practical, obstacles also present challenges to dental vaccine programs. In a recent op-ed published by the ADA, Dr. Joseph Kwan-Ho Yun outlines several of these, including a lack of training, a lack of adequate medical history, and payment and billing practices.

These challenges are certainly not insurmountable, and Kwan-Ho Yun acknowledges the benefits of such programs.

“Dentists may find it beneficial to focus on seasonal and targeted interventions such as the flu and HPV vaccines,” said Kwan-Ho Yun.

Regardless of how dental vaccine programs evolve, it is also apparent that dental-medical integration is both a prerequisite and an outcome. “This policy furthers integration of dentistry and medicine,” said Kwan-Ho Yun.

Outlook for Dental Vaccine Programs

Will your next vaccine be administered by a dentist?

Scope of practice expansions are under consideration in multiple states, and it is clear that dental professionals have the experience and expertise to play an important role on the frontlines of improving and protecting public health through vaccination, especially for HPV and seasonal diseases like influenza.

The coronavirus pandemic, in particular, presents a unique opportunity and may prove to be the impetus for driving policy changes necessary to expand dental vaccine programs nationwide.

Let’s hope so.

“Dental professional-administered vaccines, especially for oral health-related diseases like HPV, can have a tremendously positive impact on increasing vaccination rates, improving population health, and encouraging dental-medical integration,” said Dr. Zach Brian, NCOHC director. “It will be prudent that oral health stakeholders further explore this opportunity, and collaboratively enact policy to accomplish it.”

To join the effort to improve access and equity in oral health care in North Carolina, sign up to become a member today. Membership is free and by joining you’ll get instant access to our exclusive resources, events and updates for oral health advocates.