Our mouths are an integral part of our bodies, serving as the portal to many essential functions. However, within our medical system, oral health is separated from general practice. In far too many cases, patients with poor oral health that goes untreated can develop major, chronic conditions and even fatal diseases.
Poor oral health indicators are especially a concern in Kentucky, which ranks near the bottom of many indicators, including tooth decay and edentulism (tooth loss).
In this episode of Health Three60, “The Hidden Life of Your Mouth,” Renee Shaw and guests discuss the barrier that exists between dentistry and the rest of the health care system.
They also examine the growth and success of school-based oral health programs for Kentucky’s children, and talk about how treating more of the state’s underserved population will help people become healthier, more socially confident, and better prepared for the workforce.
Poor Oral Health a Gateway to Systemic Problems
KET pays a visit to the New Life Day Center in Lexington, a day shelter for people experiencing homelessness. Recently, New Life reached out to the Bluegrass Community Health Center to set up a mobile health care clinic for its clients. In addition to glucose and blood pressure screening, HIV screening, behavioral health services and the like, the BCHC also conducts dental exams and administers fluoride varnish.
“[Our clients] have more pressing issues than oral health, and it’s usually one of the last things they think about,” says New Life executive director Tyler Hurst. “So whenever I see someone, which is often, with an oral health problem, they often have an abscess or severe tooth decay.”
“We are not dentists, but we do know the importance of the integration of oral health,” says Donna Agee, RN, clinic operations manager with BCHC. “So recognizing what can happen with diabetes, heart disease, [and] all of the long-term chronic conditions that can hurt from oral health is so important, we feel like we have to address that in the primary care setting.”
Renee’s first guests are Julie Watts McKee, DMD, dental director for Kentucky, and A. Stevens Wrightson, MD, medical director and interim chief executive officer of BCHC. McKee and Wrightson discuss several diseases that are impacted by poor oral health, including cardiovascular disease, diabetes, osteoporosis, and some forms of cancer. McKee also says that oral health is vitally important for expecting mothers.
Both guests say inflammation is the main gateway by which oral health problems can transfer to the rest of the body. “If you have an abscess, and the abscess is that pus-filled sac at the end of a dying tooth root, it can get into the blood system, and you automatically have sepsis,” McKee says. “Sepsis is never good. And so what it does is, the bacteria that is part of that turns on our inflammation system, so it irritates our blood vessels and our other things going on.”
McKee and Wrightson believe that in recent years, the medical community has finally begun to realize that oral health care should be incorporated into the broader health care system. The reasons oral health has remained separate for so long are varied, but both guests say that insurance policies and government reimbursement rates for dental care need to be revised.
“There are dozens of reasons we have a divided system, and one of them is reimbursements,” McKee says. “Dental insurance has not progressed over the years like medical insurance has. I can’t imagine having to pay a 50 percent co-pay to have your knee reworked for function, but you have a 50 percent co-pay to have your mouth reworked for function. That makes no sense to me.”
“Medical providers are facing the fact that our reimbursements are going to be tied to how well our patients are doing – to patient outcomes,” Wrightson says. “The more evidence we have that demonstrates our patients are going to do better if their oral health is addressed, that’s going to support the insurers providing the appropriate reimbursement, both to physicians and I think to dentists down the road.”
Wrightson says that programs such as the one administered by BCHC at New Life will become more widespread. He also credits nurse practitioners out in the rural areas of Kentucky for adding oral health to their checklists when treating patients.
Integrating oral health into overall wellness care is “the only way we can get total body health,” McKee says. “Former surgeon general C. Everett Koop said, ‘Do not consider yourself healthy unless your mouth is healthy as well.’ And it’s so true.”
Successful School-Based Prevention Programs
KET’s production team next heads to Barren County High School in western Kentucky. There and at other nearby schools, officials with the Barren River Health District are treating children by implementing a comprehensive prevention program for oral health.
The Mighty Molar program sets up a makeshift clinic in each school. Students first get an oral exam, and then a cleaning. At appropriate intervals, fluoride varnish and/or dental sealants are applied. Sealants in particular have been proven to be very effective preventive measures for children, says Stacy Trowbridge, PHRDH, dental services director for the Barren River District Health Department.
Children with more serious issues that require major intervention are referred to area dentists. The program continues to expand outreach since starting in 2010, and health officials and educators alike see the results.
Renee and Dr. McKee are joined by Trowbridge and Nikki Stone, DMD, mobile dental outreach director for the University of Kentucky’s North Fork Community Dental Outreach Program in eastern Kentucky.
Trowbridge says that the Mighty Molar program served about 3,700 schoolkids last year. Sixty percent of them were covered by Medicaid, but 40 percent were uninsured. She says that for most kids, Mighty Molar serves as their only dental visit of the year. The program’s ultimate goal is to find a permanent dental home for each child, and Trowbridge says that most of them have been matched with dentists.
Stone’s program runs a Ronald McDonald Care Mobile Unit serving four counties in Appalachia: Leslie, Perry, Knott, and Letcher. This region has some of the highest tooth decay rates in the nation. She also runs a Head Start program that treats preschool children, and even infants. “We try to reach kids as early as we possibly can,” Stone says. “Because the earlier you reach them, the more that preventive effort is going to have an effect later on in life.”
McKee discusses another growing and successful school program that utilizes public health dental hygienists. Next year, there will be 10 such programs serving different regions in Kentucky, encompassing 27 counties, McKee says. “One of the statistics that I’m really excited and proud about is, of all the patients that we see through this public health hygiene program, 90 percent of those who need care have received care.”
Stone has seen a 20 percent reduction in tooth decay rates for the children in her eastern Kentucky region since the mobile clinic began operating about 10 years ago. Still, she says that 5 out of 10 kids in the service area have some tooth decay, which is unacceptable. Her experiences have strengthened Stone’s resolve to improve oral health in Appalachia, and she believes that if that happens, educational performance and economic opportunity in the area will benefit.
“Poor oral health completely impairs a child’s ability to learn and to get ahead in life,” Stone says. “And we know that 80 percent of decay is found in 20 percent of the population, so we’re talking about a disease of poverty. We’re talking about children who already have a lot of barriers. When they have a toothache, and they can’t concentrate, and they can’t learn in school, then that just creates this repetition to all of those barriers in poverty.”
In many parts of the commonwealth, consuming sugary beverages is a part of daily life. All three guests stress that changing this ingrained habit is absolutely necessary to improve the oral health of Kentucky’s population.
“Kentucky and eastern Kentucky have an incredibly high intake of sugar-sweetened beverages over the nation,” McKee says. “And, some people would disagree, but they are not necessary to life. You don’t have to have them. But they are very important culturally in our society. … We’re not anti-pop all the time. We’re not. But pop should be a special treat, instead of sipping on that 20-ounce Mountain Dew all day long, where you’re bathing the teeth in sugar and acid.”
As a way to change attitudes, Stone developed the Drink Pyramid, an educational tool modeled after the iconic USDA Food Pyramid. The Drink Pyramid lists consumption recommendations for four beverages from most common to least: Water Whenever, Milk with Meals, Juice Just Once, and Pop with Parties.
“It has changed drink behaviors,” Stone says. “We know that 80 to 90 percent of kids remember the Drink Pyramid after seeing it one time.” The Drink Pyramid has been adopted by other oral health programs in Kentucky, and outside of the state as well.
How Oral Health Impacts Quality of Life and Employment
PBS’s Frontline traveled to Grundy, Virginia, about 45 miles southeast of Pikeville, to report on a large free clinic staged by the Remote Area Medical charity. The clinic serves a diverse group, many who travel from distant towns to this Appalachian hamlet. All have one thing in common: a lack of resources to pay for dental care.
The clinic is a godsend for many, but has limited services. It exists as a last-resort option for people with oral health problems that, for a myriad of reasons, were not addressed for many years and now require urgent attention.
Renee and Dr. McKee are joined by Lee Mayer, DMD, associate professor and director of community dental health at the University of Louisville’s School of Dentistry.
McKee and Mayer explain that most dental services are not covered by private medical insurance, nor through Medicare. Medicaid coverage for adults is limited and varies state by state. For most people, dental care is an out-of-pocket expense, and a very expensive one for those with poor oral health.
“Dentistry is expensive, and when you’re looking at your family budget, am I going to take care of my own mouth because it’s not keeping me up at night yet, or am I going to be able to buy the groceries, or make sure that my kid has his medication?” McKee says. “Unfortunately, the dental priority doesn’t come to the top until it keeps you up at night, therefore it costs more and you may lose a tooth.”
Once that point is reached, oral disease has compounding impacts on daily life. In addition to the various maladies that tooth decay and periodontal disease contribute to, afflicted persons will encounter social prejudice due to their appearance. The constant pain will also severely affect job performance, or the ability to land a job.
“Employers generally want people who are healthy, and that should include their dental health,” Mayer says. “It improves productivity. Employers generally don’t want people who are going to miss work and may not represent their company well. Also, it affects insurance premiums if a company happens to provide health insurance.”
McKee and Mayer both highlight the unequal distribution of dentists in Kentucky as another barrier to care. That comes into play even more when considering the fact that many low-income people lack reliable transportation to get them to the nearest dentist that accepts Medicaid patients, which may be a county or more away.
Kentucky’s expansion of Medicaid under the Affordable Care Act led to a surge of new patients arriving at dentists’ offices, McKee says. In many cases, these patients had such pent-up dental problems that the only effective treatment for them was tooth removal, either partial or full mouth. That placed many low-income patients back in a financial bind, Mayer notes, because adult dental Medicaid coverage in Kentucky does not cover replacing missing teeth.
Both McKee and Mayer say that getting dentures is no panacea for oral health problems and that dentures greatly reduce functionality compared with natural dentition. They both stress that Kentuckians’ oral health quality will improve only when enough people learn and practice comprehensive preventive care. The state has made good progress in preventive oral health this century, but needs to build on that momentum, the guests say.
“Preventive care is the best care,” Mayer says. “It is the least expensive care, not only over time, but initially. As I grew up, dental care was basically reparative care, which is very expensive. Now they call them ‘full mouth rehabilitations.’ And that’s the result of not taking care of things and preventing future problems.
“I think that the major thing to realize is that oral health is part of your systemic health,” he adds. “If you take care of a sore on your hand, you need to take care of sores on your gums, and you need to take care of an infection in your mouth. It’s a wellness thing. “
This KET production is part of the Inside Oral Health Care initiative, funded in part by the Foundation for a Healthy Kentucky.
