Challenging Dogma


...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

Inadequate Oral Health Coverage by DentiCal Translates Into Poor Health Outcomes – Mario Orozco

The belief that oral health is separate from health, the individualistic and non-preventive approach of dental interventions, the biomedical focus followed by universities and the poor access to dental services led to flawed interventions from which U.S. welfare recipients are victims.

Research has concluded that the nation’s oral health is the best in history, but that dental diseases, which are largely preventable, remain far too common across the nation. In 2000, the surgeon general issued a report describing the silent epidemic of dental and oral diseases affecting mainly the poor, but some specialists, including those at community clinics, say the problem is becoming worse. (1)

Eighty percent of tooth decay is found in 25 percent of children concentrated in minority populations and less than 10 percent of low-income minority children aged eight are protected by dental sealants. Moreover, poor adults, elderly and members of racial and ethnic groups have a higher percentage of untreated decayed teeth and experience higher levels of oral health problems. Oral health ailments such as dental caries, cancer, gum disease, edentulism, oral-craniofacial injuries and birth defects afflict more Americans than any other cluster of health problems. (1-3)

DentiCal, Medicaid’s segment that runs dental benefits in the state of California, has limited preventative services in their scope of benefits. Among them, two yearly dental cleanings, sealants and twice-a-year fluoride applications are allowed to children less than twenty-one years of age. In the case of adults, the benefits cover mainly secondary and tertiary interventions rather than preventative. For instance, a baseline examination is covered only once a year, most regular fillings, as well as emergency procedures and extractions are covered with the adequate documentation that justifies the procedure. However, important preventive procedures such as fluoride home treatment, which helps to prevent tooth decay, and interproximal hygiene instructions are not considered within the scope of benefits. Although these interventions are acceptable in the sense that they cure an immediate need; and considering that many states do not even offer dental services to adult Medicaid recipients, they are focused on interventions when disease is at advanced stages. Prevention does not play an important role in the benefits, and one can almost assure that the burdened providers that accept DentiCal patients in their practices -- which mainly include community health centers, universities and public hospitals -- seldom render such interventions.

Given the dimensions and impact of oral health diseases that affect not only lower income populations, but also the public in general, MediCal has failed to make prevention a star priority in their scope of services. The influence the biomedical model has in the designing of health programs across the nation, as in the case of California, and the historical divorce of Medicine and Dentistry that began in the 20th Century, created a problem in the delivery of health services that affects every sector of the population.

The biomedical model fed an optimism that the union of technologic innovation and expertise in basic science would produce cures for most human afflictions (4). Consequently, health providers were trained in diagnosing and treating disease in individuals. They look at cells, organs and systems but not at people who are part of an ecosystem. Thus, DentiCal only attempts to treat proximal causes of oral disease, whereas fundamental causes are not addressed nor put into the context of the community. Universities have failed to prepare professionals that can envision solutions through dynamic relations with patients that may provide further information about who they are and what they need.

Preventive treatments have not been prioritized because they are regarded as “easy” to perform, and do not involve great scientific or advanced technology. Thus, patients do not feel they benefit from them, unless a “doctor” performs a “complex” intervention. The valuable exchange of counseling is not appreciated in dental settings and if one dares to charge for those consulting services, patients are likely to feel offended and even abused. From the viewpoint of the provider, anything that does not involve drilling or sophisticated techniques is regarded as time wasting, and something that can be done by a “less trained-educated” provider. This is an attitude that has influenced our society and from which MediCal became a victim as well.

Nancy Krieger, clearly states that the biomedical model emphasizes biological determinants of disease amenable to intervention through the health care system, considers social determinants of disease to be at best secondary (if not irrelevant), and views populations simply as the sum of individuals and population patterns of disease as simply reflective of individual cases. In this view, disease in populations is reduced to a question of disease in individuals, which in turn is reduced to a question of biological malfunctioning. This biologic substrate, divorced from its social context, thus becomes the optimal locale for interventions, which chiefly are medical in nature. (5)

As administrator and auxiliary dental provider in a community health center in Oakland, California, I experienced the positive results of providing preventive interventions among Latino families, mostly recipients of DentiCal. Every family was required to attend an educational talk on oral health before starting any other dental intervention, especially if they involved procedures of secondary and tertiary levels of attention. This primary intervention not only involved the disclosure of bacterial plaque—the direct biological agent that causes caries—but also the instruction of plaque control by the use of mechanical and chemical agents. The invention was not the instruction, but rather the concept that the health belief model does not incorporate, of bringing a collective to learn and do in an environment that encourages help and support among family members. This intervention brought some features of the social cognitive model and the social learning theory, which fulfills the gap that the health belief model has when assuming that everyone is able to make rational decisions, especially when the groups more prone to oral disease are young children, the elderly and the special needs population. This, added to instructions in nutrition on avoidance of cariogenic foods was much more than I have witnessed in other centers for which I had worked in the San Francisco Bay Area.

Working integrally with other health providers is fundamental to prevent oral diseases that highly affect these populations. Cardiovascular disease, diabetes, obesity, pneumonia, low weigh offsprings, among others are the result and can be exacerbated by oral diseases such caries and periodontal disease. All of them can be prevented by promoting healthy lifestyles such as tobacco cessation, good nutrition and exercise, which may eventually translate into positive outcomes. Economically speaking, the money that a state may save could be invested in educating these populations as a means for fighting poverty and other social, economical and political factors that influence public health. Unfortunately, MediCal has failed in promoting such interventions, and the preventive intervention instated in the community dental clinic in Oakland is not covered, which leaves the most vulnerable population at a higher risk and perpetuates a never-ending vicious cycle.

In general, rural and urban low-income communities are in greater need of dental services, and yet they are the ones that suffer shortage of dental professionals more frequently. Moreover, being disabled, medically compromised, homebound, or institutionalized increases the likelihood of serious dental problems and limited access to dental care. The lack of access to oral health care services is compounded by a shortage of skilled geriatric and pediatric dental care professionals. In addition, there has been a significant decline in the number of practicing dentists over the past twenty years, and a projected decline in dental school graduates—the percent of graduating dentists declined by 40 percent between 1986 and 2000.(6)(7)

Besides the overall shortage of dentists, dental providers tend not to extend their practices to DentiCal recipients, because they require more time consuming work, at a very low reimbursement rate. Thus, DentiCal patients have fewer places to go. These places include mostly teaching hospitals and community health centers that soon see their services exhausted, which compromises the quality of their services and the health of the people. At the pediatric dental clinic at the University of California San Francisco, children have to wait for over three months to have a regular check up or a filling, while those who require dental attention under general anesthesia due to mental or systemic illnesses may have to wait for over six months while their health worsens. Therefore, including more preventive group-guided interventions may help balance not only the shortage of dentists in the state of California that serve DentiCal, but also would improve the quality and coverage of services and reduce the need of more intrusive, time-consuming and expensive interventions.

Although DentiCal has failed to provide adequate benefits to its recipients, the problem is not rooted in their own particular policies, but rather, DentiCal is victim of a system that dictates its plans based upon models that are obsolete. They have failed to integrate social, economical and political factors that are elements of the complexes that make up a cause of a disease. When public health practitioners get to accomplish the task of viewing causes and diseases in an integrated universe, this would be the time for that revolution to happen, and then it all will come down to “disease is caused by injustice and inequalities brought by a battle for power in societies”. Public health as a discipline has fallen short in changing that, and its capacity of opening to other social sciences will be fundamental for such change in the paradigm.

References

1. Abelson, Reed. “Dental Double Standards” The New York Times 28 December 2004. 30 November 2006

2. U.S. Department of Health and Human Services. The Oral Health in America National Grading Project 2003: National Grade C. Keep America Smiling. Rockville, MD: U.S. Department of Health and Human Services, 2003

3. Dental Health Foundation. Mommy, It Hurts to Chew” The California Smile Survey: An Oral Health Assessment of California’s Kindergarten and 3rd Grade Children. February 2006

4. Bodenheimer T, Grumbach K. How Healthcare is Organized ( pp. 46-58). In: Bodenheimer T. Fourth Edition. Understanding Health Policy: A Clinical Approach. New York, NY: McGraw-Hill, 2005

5. Krieger N. Epidemiology and the Web of Causation: Has anyone seen the spyder? Soc. Sci. Med., 1994; 39:887-903

6. U.S. Department of Health and Human Services. An Oral Health America Special Grading Project: National Grade D. A State of Decay: The Oral Health of Older Americans.. Rockville, MD: U.S. Department of Health and Human Services, 2003

7. Center on an Aging Society. Oral Health Care: Can access to services be improved? Center on an Aging Society. Georgetown University. Challenges for the 21st Century Chronic and Disabling Conditions. 6: April 2004

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