Shelly Gehshan The Gap in Dental Care

Five Questions

An unemployed, 24-year-old Ohio man died in late August after a tooth infection spread to his brain. An emergency room physician had prescribed an antibiotic for Kyle Willis but he had no dental insurance and couldn’t afford to fill the prescription.


Adults without dental care often lacked care as children. The Ohio incident recalls the tragic death of Maryland 12-year-old Deamonte Driver, who died in 2007 of an untreated toothache because his mother could not find a dentist to treat her Medicaid-enrolled son. Nationwide, more than 16 million children go each year without seeing a dentist. Pew’s Shelly Gehshan discusses the gap in care.

Q: Stories like that of Kyle Willis or Deamonte Driver generate national attention. But what do they tell us about the overall dental care system in the country?

A: People need to know that we can fix this problem. We can fix it partly by educating people about prevention and how and when to seek care. But we also have a system that doesn’t work well for certain populations. If you’re in a rural area, if you’re low-income, if you’re uninsured, you are going to have a lot of difficulty accessing dental care as it is currently structured. The safety net system consists mostly of federally subsidized clinics, and they’re effective, but they only reach about 10 percent of the underserved. We need to expand the safety net so it reaches the people who need the care before crises occur.

Q: In 2010, the Affordable Care Act was enacted. Will the new law help to improve children’s access to dental care, especially for low-income populations?

A: The policy community scored some important victories with health care reform, and one of them is that all children will have dental coverage by 2014. That is good news, but it also presents a challenge. About 5 million more children will have dental coverage than have it now, and we already have access problems.

Our advice to states is, get ready, expand your system, do as much prevention as you can, look at your dental workforce and get moving.Shelly Gehshan, Director, Pew Children's Dental Campaign

Because we’re not prepared to take care of what is going to be a huge influx of children who need and deserve care.

Q: What can states be doing between now and 2014 to ensure they are better prepared to serve all of the children who will have dental coverage under the new health care law?

A: States have a lot of options. About a dozen are looking at new types of dental providers they can develop. There are several different models. One is adding new training for hygienists, so they can perform a broader range of services. Another model allows community health workers to perform different types of dental services. A third model uses what’s called a dental therapist, which is a primary care provider who can do routine care, similar to a nurse practitioner or a physician’s assistant. Minnesota passed a law that established two new types of providers. A number of other states are also looking at how to use the existing workforce, meaning hygienists and dental assistants, to expand the capacity of clinics and dental practices.

Q: Pew has been working with the American Academy of Pediatrics and Voices for America’s Children to get pediatricians more involved in oral health. What impact has that made?

A: What we have done together is increase the number of states where Medicaid agencies reimburse pediatricians for providing preventative dental care to young children. We went from 28 states having approved reimbursement in 2008 to 44 now adopting this policy. For example, Oklahoma decided in August to reimburse pediatricians for administering fluoride varnish, which is a huge victory.

Most young children don’t see dentists—they see pediatricians. Those pediatricians can educate families, they can look in a child’s mouth and they can put fluoride varnish on the teeth to prevent decay. Getting pediatricians involved is a good thing, and we’ve been honored to partner with those groups and get that policy change moving.

Q: What can states do in these tough fiscal times to meet the need for better access to dental care?

A: The best thing they can do is make sure their water is fluoridated because that’s a cost saving measure, as well as a proven preventative measure. For most cities, one dollar spent on fluoridation saves $38 in treatment costs.

The second thing they have to do is make sure they have an adequate workforce to take care of under-served children. Most states have a serious shortage of dentists. We’ve got the lowest dentist to population ratio we’ve had in 100 years. We also need new types of providers who can work with dentists and hygienists and augment the care that is available.

The third thing states should do is seriously look at expanding dental sealant programs for low-income kids. They certainly shouldn’t cut back existing programs. Just last week, the Georgia Board of Dentistry voted against a proposed rule that would have restricted hygienists' ability to apply dental sealants in public health settings. Sealants are a proven, effective public health measure, and right now the kids who need them most are the least likely to get them. If Deamonte Driver had gotten a $40 sealant on his tooth, perhaps he’d be alive today.

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