Providing Oral Health Care to Vulnerable Populations

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• Providing Oral Health Care to Vulnerable
  Populations
• Barry Daneman
• UMKC School of Dentistry
• September 14, 2003

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Characteristics of Vulnerable Populations

• Vulnerable populations include the following
• low-income families
• single-parent families
• families in underserved communities
• the elderly
• non-English speaking families
• persons with developmental and mental
  disabilities
• medically compromised
• under-represented minorities

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Low Income Families

• Many lack dental insurance and cannot afford to
  see private dentists.
• Many have no regular source of care (dental
  home).
• Those who depend on Medicaid often find it
  difficult to locate a participating dentist
  thats accepting new patients.

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Low Income Families

• Are less likely to have reliable private
  transportation
• Are more likely to rely, where its available, on
  public transportation
• Are more likely to have difficulties keeping
  appointments

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Low Income Families

• A study by the GAO found only 42 of Missouri
  adults with family income of lt 15 K have an
  annual dental visit, compared with 70 of those
  with incomes gt 35 K.
• In Kansas, 45 of adults with incomes lt 15 K had
  an annual dental visit compared with 76 of
  those with incomes gt 35 K.
• The study also found that only 27.1 of
  Medicaid-enrolled children in Missouri had an
  annual dental visit 38.9 in Kansas.

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Low Income Families

• A study by the Childrens Dental Health Project
  found that, nationally, fewer than 20 of
  children eligible for Medicaid (i.e., enrollees
  plus those who fail to enroll) receive dental
  care in any given year.
• Medicaid-eligible children have a high rate of
  dental morbidity 80 of all dental caries are
  found in the 25 of children, who come from the
  lowest income classes.

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Low Income Families

• Children from low income families are 50 less
  likely to have their dental caries treated than
  children from middle-income families.
• The consequences of untreated dental caries
  include pain, loss of appetite, mental
  distraction, tooth loss, disfigured smiles,
  speech pathologies, emotional distress, academic
  problems and behavioral issues.

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Single-Parent Families

• Are disproportionately headed by working mothers
  with low incomes
• Single working moms are not always able to take
  off work for personal or childrens dental
  visits.
• Single moms with more than one child often have
  care-giving conflicts that make it difficult for
  them to keep appointments.

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The Elderly

• Often have income issues, transportation needs
  and care-giving conflicts.
• Medicare, the federal health insurance plan for
  the elderly, offers no dental benefits.
• Institutionalized elderly have special access
  issues.

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Insurance coverage among adults aged 18 and older
by age
Data source 1997 Behavioral Risk Factor
Surveillance System, Centers for Disease Control
and Prevention.
16.1.1
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Percentage of the U.S. population that visited a
dentistwithin the past year by age group
Data source The Third National Health and
Nutrition Examination Survey (NHANES III)
1988-1994, National Center for Health Statistics,
Centers for Disease Control and Prevention.
7.1.1
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Percentage of the population who received
preventive dental services during 1997 by type
of service and insurance status
Note Sample size for uninsured receiving
fluoride services was insufficient to produce
reliable national estimates. Includes seeing
general dentist, dental hygienist, or dental
technician. Data source 1997 Medical Expenditure
Panel Survey Household Component, Agency for
Healthcare Research and Quality.
7.8.3
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Families in Underserved Communities

• Many rural and inner-city urban communities find
  it difficult to recruit and retain oral health
  providers.
• Since 1992, the number of dental health
  professions shortage areas designated by the U.S.
  Bureau of Health Professions increased from 792
  to 1,895.
• More than 8,000 new dentists are needed in these
  communities to meet the needs of over 40 million
  people.

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Non-English Speaking Families

• Find it more difficult to learn about the
  Medicaid and CHIP programs, get enrolled and
  locate participating providers
• Have difficulty communicating needs and problems
  to providers, understanding self-care
  instructions

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Persons with Developmental and Mental
Disabilities

• have greater dental morbidity than general
  population, less well-developed self-care habits,
  difficulty in making and keeping dental
  appointments, less compliant with treatment
  advice
• The mentally ill often use psychotropic drugs to
  manage their symptoms such drugs cause Xerostoma
  (dry mouth), which increases incidence of tooth
  decay and gum disease.

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Medically Compromised

• (e.g., persons with cancer, cardiovascular
  disease, kidney disease, diabetes, AIDS)
• Often cannot find private general dentists who
  can treat them.
• Lack income and insurance coverage for needed
  services.
• Often have life-threatening conditions.

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Percentage of dentate adults aged 50 and older
with andwithout diabetes who visited a dentist
within the past yearby federal poverty level
(FPL) and education
Types of dentists include dental hygienists,
orthodontists, oral surgeons, and all other
dental specialists. Data source 1998 National
Health Interview Survey, National Center for
Health Statistics, Centers for Disease Control
and Prevention.
15.2.2
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Under-represented Minorities

• African-Americans, Hispanic-Americans and Native
  Americans are less able to access dental care
  than Non-Hispanic White Americans.
• They are more likely to have untreated dental
  disease and they experience more severe
  consequences from dental disease.
• They are less likely to be dentists or dental
  hygienists.
• They are less likely attend dental school or
  dental hygiene school.

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Disparities in Disease Frequency
Source CDC, NCHS, NHANES, 1988-1994, HIS (AI/AN)
and California data (Mexican Americans)
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Disparities in Disease Burden
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Race/Ethnicity of US Dentists
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Race Ethnicity of Dental Hygienists
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Missouri Dental Grads
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Missouri Dental Hygiene Grads
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Kansas Dental Hygiene Grads
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What to do?

• Strengthen Medicaid
• Expand Dental Work Force
• Create Community Campus Partnerships
• Develop Alternative Service Delivery Arrangements
• Organize Oral Health Coalitions
• Educate Patients/Care-Givers about Oral Health

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Strengthen Medicaid

• Only one in six dentists nationwide actively
  participates in Medicaid
• Low reimbursement
• Burdensome paperwork
• Unreliable patients
• To improve participation, we need to increase
  fees, streamline claims process, provide case
  management.

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Expand Work Force

• Increase the number of dentists and dental
  hygienists
• Provide incentives for dentists and hygienists to
  practice in underserved communities (rural and
  urban core)
• Modify dental practice act to enable dental
  hygienists and assistants to take on expanded
  functions

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Expand Work Force

• Recruit collateral professions to provide
  preventive dental care (e.g., doctors, nurses,
  medical assistants)
• Establish clinical rotations for dental and
  dental hygiene students in public health settings
  in underserved communities

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Community Campus Partnerships

• In addition to clinical rotations, develop
• Community based residency programs
• Community education programs (aimed at parents,
  children, school teachers)
• Sealant programs
• School-based clinics

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Alternative Delivery Arrangements

• Mobile dentistry programs (e.g., dental vans,
  portable operatories)
• Volunteer Dental Clinics (staffed by volunteer
  dentists, dental hygienists and assistants)
• Community health centers (FQHCs)

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Oral Health Coalitions

• Recruit diverse group of stakeholders dentists,
  dental hygienists, primary care medical doctors,
  school nurses, teachers, social workers,
  insurers, employers and unions, community health
  centers, hospitals, funders, churches, media
• Advocate
• Educate
• Organize

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The Partnership for Smiles
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• Faculty and students from UMKC School of
  Dentistry rotate through five Greater Kansas City
  community health centers.

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Cabot Westside Clinic
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Kansas City Free Health Clinic
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Seton Center
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Samuel U. Rodgers Community Health Center
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Swope Parkway Health CenterNorthland Health
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