The Oral Health in America report provides a road map on how to improve the nation’s oral health. Why is it important to create this road map?
When we think about the first report, it was significant that it began to really inform the public about the importance oral health has in overall health. It really strengthened the old saying that the mouth is part of the body; it’s not a separate entity. Also, it’s not just about teeth. It’s about all the things that influence oral health. This report really strengthens the interconnection between oral health and overall health; it makes it abundantly clear that oral health is integral to overall health and quality of life.
Also, this report points out that even though we’ve made all of these fantastic advances, we still have a lot of remaining challenges, with one of the most important being access to care. We still have some serious issues with access to care.
Dental expenses constitute more than a quarter of overall healthcare out-of-pocket expenditures and are reported to present higher financial barriers than medical, pharmaceutical and mental health care – especially for working-age adults. What is behind this problem?
Out-of-pocket dental expenditures are a very important concern. In our country, we have an unusual situation in that we’re almost at 100% universal dental health coverage for kids because of either private insurance or public insurance like Medicaid, Children’s Health Insurance Program (CHIP) and coverage under the Affordable Care Act (ACA). So, over 90% of kids have dental insurance. The out-of-pocket expenditures for kids is not nearly what it is for working-age adults whose insurance is mostly based on their employer. About 2 out of 3 adults have some type of dental insurance.
It's even worse for older adults. At least half of senior citizens don’t have dental insurance. For those who do, many are buying insurance through a Medicare Advantage plan, so it’s an out-of-pocket expense. So, you go from almost universal dental coverage for kids to only half of the older-adult population who are covered. Out-of-pocket dental costs become a bigger issue the older you get.
Also, compared to the pharmacy and even mental health expenditures, dental care is more likely to be deferred because of costs, especially for working-age adults. It’s driven by tight budgets and costs for care, so working-age adults and seniors are more likely to defer dental care.
What are the new research discoveries and technological advancements that have especially reshaped dental care in the last 20 years?
We’ve had substantial advances in science and technology – it has dramatically improved the delivery of dental care in the last 20 years – but that has not helped everyone. Technology is great, and we can do a lot of things now that were only aspirational two decades ago, but the societal tradeoff is increasing oral health disparities because the higher costs associated with newer technologies is a major driver of dental costs affecting affordability of care for many.
One of the most fascinating advances has been in the area of everything being digitized. The current generation of dental students are learning things that were a dream 20 years ago. Digital records, radiographs, images, impressions, intraoral scanning and fabricating. These things have made things easier for patients. They can now get crowns and dentures made and delivered more accurately and quickly. Dental implants have also exploded in the last 20 years in use with newer technologies and treatment generating substantially better outcomes for people. Technology has really advanced some of the ways we deliver care, but all of that has been with the more expensive type of treatments.
Other great advances in science and technology that are helping us to learn more about oral health are related to discoveries in the oral microbiome, plus the advances in genomics, gene-editing technology like CRISPR. The promise of this new knowledge is laying the groundwork for more precision oral healthcare.
Is headway being made on social determinants – group disparities around oral health – or are they as big a problem today as back in 2000?
The understanding of the role that social determinants play in health and in disease has expanded dramatically in the last 20 years, in both oral health and overall health. I think of the social determinants of health broadly – such as where we live, where we work, the community in which we live, our families – all of those influence health and health outcomes. Age, sex, race and ethnicity, our cultural influences play a role, too. One of the most important factors is our zip code: It can be very predictive about what our prevalence of disease is, what our incidence of disease is going to be, how our health outcomes may change as we age.
This is definitely an area in which we have substantially more information (compared to 2000), but it’s also an area that’s very hard to translate into effective change when you think about the regular doctor-patient relationship, because that relationship can’t change the social determinants that affect health. That requires a public policy intervention rather than a clinical chair-side intervention. It’s not just scientists, clinicians and patients all trying to do the right thing on the individual level, but there’s also a societal requirement for interventions at the community level. For example, poverty elimination alone would go a long way toward helping a lot of people enjoy much better health outcomes.
How has COVID-19 impacted oral health in America?
I remind people that COVID was a shock to dentistry much in the same way that HIV was. HIV really introduced this whole notion of heightened infection control and the processes that dentists use now. That epidemic really incentivized dentists to wear gloves and masks, to expand sterilization and disinfection procedures to ensure that transmission of the virus in a dental practice was virtually impossible. Many people forget that back in the early ’80s, dentists were not routinely wearing gloves.
COVID’s done the same thing. It’s required us to revisit our infection control procedures and improve our protocols to really ensure patient safety in delivering care. Unlike the HIV epidemic, there was a widespread temporary closure of dental practices due to lock-down measures. Nationwide, I believe general dental practices are now up to about 75% capacity, and the whole dental economy is trying to get back to pre-pandemic levels. The negative effect has been a significant increase in unmet and deferred dental care.
An odd byproduct of the pandemic has been a greater recognition of how essential dental care is. Early in the pandemic, when many states were legislating closures, they exempted essential medical care. In many cases, dental practices were not exempted because it was not considered essential. This was raised at the national level by a number of organizations, and it has created a movement toward recognizing dental care as essential healthcare. That’s been a positive step, because it circles back to that whole notion about oral health being integral to overall health.
Given what’s been learned in research that’s gone into the report and research in dental health, what’s the country’s biggest oral health issue that needs to be addressed in the next decade?
I would say it’s the issue with our senior citizens. Our country is aging fast. According to the census, we’ll have more older adults than youths – ages 18 and younger – by 2034. Just three years earlier, the census predictions said that would happen by 2035 – so it’s accelerating.
When you add that half of the older adult population is not covered by dental insurance, that’s a big issue. People are living longer, they’re living with more chronic diseases, resulting in conditions that reduce one’s quality of life. Tooth decay and gum disease are chronic diseases and deferred treatment can lead to pain, infection and tooth loss. Having a dental benefit in Medicare or some other type of insurance would be helpful, but we need to figure out a way to provide some sort of dental coverage to improve access to care for older adults. The CU Multidisciplinary Center on Aging recently reported that Colorado is now the fastest-growing state for those 65 and older.
Any other thoughts about oral health in America?
I would say one of the most important advances in the last 20 years has benefited those on the early side of the lifespan – the reduction in untreated tooth decay in preschool children – as the prevalence has nearly been cut in half. We went through decades where the prevalence remained virtually unchanged, and then all at once prevalence declined dramatically right after the mid-2000s. I believe that’s a great example of what improving access to care can do. This was around the time of CHIP reauthorization, Medicaid expansion, the ACA was enacted and the children age group benefited most as many uninsured kids got dental insurance. There were other important activities around that time too, such as professional organizations encouraging caregivers to have the first dental visit at age 1. So, substantially tooth decay, which is the most prevalent disease worldwide, among preschool kids, is a really important milestone for the country.