Indigent dental care in Virginia: An update.

I wrote a lengthy piece on the state of indigent dental care in Virginia a few years ago. It continues to be read regularly, and I get often get e-mail in response to it. A few days ago reader “LCS” e-mailed me the following:

I just recently went on an archives hike and came across your blog in 2006 on Dental care in Va. I was wondering if you have any updated news (or laws) on this matter. I have dental insurance but I also have weak enamel and always have cavities. I guess that’s why I’m scared of the dentists (fear from childhood visits.) Now that my teeth are all decaying, I can’t afford the 50% they want me to pay (per tooth) even with the insurance. My breath is so bad I don’t let people get close to me. I haven’t kissed my husband of 20 years in so long I have forgotten how. I could afford it if the insurance would cover more of the cost. They are good at paying for preventative work, but not for problems.

When I read this e-mail, I knew just who to direct LCS’s question to: Terry Dickinson, executive director of the Virginia Dental Association. Dr. Dickinson is well-known for his crusade to improve the health of the Virginians most in need of dental care. Just last year the National Rural Health Association honored him “for his leadership in developing and sustaining Mission of Mercy projects in Virginia, Kentucky, West Virginia and Tennessee since 2000, plus a MOM dental clinic in New Orleans for Hurricane Katrina victims in 2006.” He’s facilitated the provision of $9 million in free dental care to over twenty three thousand citizens in rural, underserved areas.

Dr. Dickinson’s response follows. Please note that I have copyedited both e-mails, but otherwise left them unchanged.

Unfortunately, I have heard stories like this with variations for as long as I have been Executive Director of the Virginia Dental Association (10 years).  Because adult dental care for the working poor and Medicaid population is not covered by Medicaid in Virginia (except for treatment that’s medically indicated—mostly extractions in the ones eligible for Medicaid), we have a fairly significant adult population in need of dental services. Some, as noted in the e-mail, fairly extensive.

Certainly, in her case, she is still better off than the many people with no insurance that usually end up in the ER receiving only palliative care (antibiotics and pain medication). She might be a good candidate for the dental school (if transportation isn’t a problem), as their fees are 30-40% cheaper than those in private practice. I am struck by her comment that she has “weak enamel and always gets cavities.” I certainly would address that issue before extensive treatment being done, as it would be unusual for someone to have a condition they couldn’t change by oral hygiene procedures and diet changes.

As you can see, this isn’t an answer or solution to this immense, challenging problem, as there are hundreds of thousands worse off than she with little or no resources.  We just saw over 750 patients last weekend in Onley on the Eastern Shore, providing $450,000 in free dentistry).  I doubt that we made a dent in the need over there, but it’s some help to those that were able to get in and see us for help. We actually had a couple come from Richmond and one from Goochland. That’s a 3+ hour drive for just the possibility of getting help.

Regarding solutions to this problem, I am definitely short on that category.  Perhaps some sort of piece in universal health care that could at least get people out of dental pain and infection.  The challenge is getting the process and progress of mouth disease to stop. That’s all about literacy, education, fluoride, and all the proven preventative methods that we know work to decrease the incidence and progress of dental decay.  We are looking at doing a model project in three health districts, starting sometime this year, to try interventions in schools and linking the dental health education piece with a community health worker that could continue the link into the home, as it is the parents making the decisions that will either help or hinder that child’s dental health.

But even as we move in that direction, we still face the shortage of providers in those rural and remote areas of the state.  The dental public health system seems to be imploding, going from a high of some 80 public health dentists to some 40 today.  And they basically only see kids.  Most are older and close to retirement, so the future of that system is rather bleak unless some systemic change occurs.  The Federally Qualified Health Centers (FQHCs) and Free Clinics may be the only safety net for dental patients in the future, as long as they continue to get federal funds and some state funds.

Another possibility could be satellite clinics, like the one proposed for Wise. This would be a clinical facility (off site) of VCU’s School of Dentistry. Five senior dental students and two dental hygiene students would spend their senior year there, instead of in Richmond. The hope is that they would then stay in that geographic area after graduation and practice somewhere in the area.  If that model proves to be viable, I could see several more down the road.  They use offsite clinics in certain Community Health Centers and Free Clinics to do some of that training, also.  I think each senior has to spend a minimum of three weeks offsite. That’s a good way to get them out into the communities with some hope of them considering coming back to practice.

The keys to the future will lie with the following:

• Literacy, education, and prevention services with linkages to the medical side through lay health workers.
• Funding the needed programs (CHCs, free clinics, public health, loan repayment incentives, community incentives, dental Medicaid (both children and adults).
• Adequate geographic and numerical distribution of providers.
• Understanding among policy makers and the public about the link between mouth disease and overall health.

It’s a huge, complex and confounding issue with fragmented resources and ideas.

I must say, I find Dr. Dickinson’s response a bit depressing. I’d hoped that there’d been some changes in state and national health policy in the past few years. The fact that our system is in such shambles—that people’s lives can be ruined for lack of dental care, and we’ve got no safety net to deal with that—is the sort of thing that I’d like to think that They™ would be taking care of.

The good news is that LCS and Dr. Dickinson are in contact, and he’s finding a way to help her. But one in five Virginians don’t have a single tooth in their head, and probably as many who are going down that path. So we just need a thousand more Dr. Dickinsons, and then we’re in good shape.